What history taking and physical examination (PE) should be done for a 23-year-old active duty male presenting with 2 weeks of cough and sinus issues?

History and Physical Examination for 2 Weeks of Cough and Sinus Issues

Critical First Step: Rule Out Serious Pathology

For a 23-year-old active duty male with 2 weeks of cough and sinus symptoms, begin by excluding red flags that would change management urgency, then systematically evaluate for the most common causes: upper airway cough syndrome (postnasal drip), viral upper respiratory infection transitioning to post-viral syndrome, and less commonly at this age, asthma or gastroesophageal reflux. 1

Essential History Components

Red Flag Symptoms (Require Immediate Investigation)

• Hemoptysis of any amount—mandates chest radiograph 2, 3
• Fever >38°C (100.4°F) persisting beyond 3 days or appearing after initial improvement ("double sickening" pattern) 2
• Severe unilateral facial pain suggesting bacterial sinusitis 2
• Acute breathlessness requiring assessment for asthma or other serious pathology 2, 3
• Prominent systemic illness with malaise, weight loss, or night sweats 3

Core Symptom Characterization

• Nature of nasal symptoms: Distinguish between rhinorrhea (clear vs. purulent), nasal congestion, sneezing, and postnasal drainage 1
• Cough characteristics: Timing (worse at night suggests postnasal drip or asthma), productivity, and whether paroxysmal with post-tussive vomiting (suggests pertussis) 1
• Duration specificity: Symptoms at exactly 2 weeks place this patient in the transition zone—typical viral URIs last 7-10 days, with 25% extending to 14 days without bacterial infection 2
• Facial pain location and quality: Persistent purulent secretions beyond 10 days with facial pain suggest bacterial sinusitis, though this is uncommon (only 0.5-2% of viral URIs develop bacterial complications) 1, 2

Environmental and Occupational Factors (Critical for Military Personnel)

• Deployment history and toxic exposures: Specifically ask about burn pit exposure, which can cause chronic nonallergic rhinosinusitis in military personnel 4
• Occupational irritant exposures: Dust, chemicals, or other airborne irritants common in military settings 1
• Barracks environment: Mold, poor ventilation, or allergen exposures 1

Medication and Substance Use History

• Current medications: No ACE inhibitors expected at this age, but document all medications 1, 5
• Tobacco use: Active smoking causes chronic bronchitis and must be addressed 1, 6
• Topical decongestant use: Overuse (>3-5 days) causes rhinitis medicamentosa 1, 2

Associated Symptoms That Guide Diagnosis

• Conjunctival symptoms (itching, tearing): Strongly suggest allergic rhinitis 1, 7
• Wheezing, chest tightness: Indicate possible asthma or cough-variant asthma 1, 5
• Throat clearing, sensation of postnasal drainage: Classic for upper airway cough syndrome 1
• Heartburn, regurgitation, sour taste: Suggest GERD as contributing factor 1, 5

Timing and Pattern Recognition

• Seasonality: Seasonal exacerbations suggest allergic rhinitis (though onset typically before age 20) 1
• Improvement followed by worsening: "Double sickening" pattern suggests bacterial superinfection 2
• Persistent symptoms beyond 10 days without improvement: Consider post-viral rhinosinusitis or bacterial sinusitis 2

Physical Examination Focus

Vital Signs and General Appearance

• Temperature, respiratory rate, oxygen saturation: Fever beyond 3 days or appearing after improvement is concerning 2, 3
• Respiratory distress signs: Tachypnea, use of accessory muscles 3

Nasal Examination (Most Critical Component)

• Mucosal appearance: Red and swollen mucosa suggests infectious rhinitis/sinusitis; pale, boggy turbinates suggest allergic rhinitis 1
• Quality of secretions: Clear and watery suggests viral or allergic; thick, yellow-green, or gray secretions persisting beyond 10 days suggest bacterial sinusitis 1
• Purulent discharge in middle meatus: Highly predictive of bacterial sinusitis, but may require topical vasoconstrictor to visualize 1
• Unilateral vs. bilateral findings: Unilateral symptoms suggest structural problem (polyp, foreign body, septal deviation, or rarely tumor) 1
• Nasal patency and anatomical obstruction: Assess for septal deviation or turbinate hypertrophy 1, 4

Sinus Examination

• Sinus tenderness on palpation: Maxillary and frontal sinus tenderness suggests sinusitis 1
• Transillumination: Limited utility but may support clinical impression 1

Oropharyngeal Examination

• Posterior pharynx: Look for increased secretions or "cobblestoning" suggesting postnasal drainage 1
• Tonsillar size and erythema: Rule out pharyngitis 1

Ear Examination

• Tympanic membrane appearance: Assess for otitis media as complication of rhinosinusitis 1
• Middle ear effusion: Common complication of upper airway inflammation 1

Pulmonary Examination

• Auscultation: Listen for wheezing (suggests asthma), crackles (suggests pneumonia or bronchitis), or normal breath sounds 1, 2
• Percussion: Dullness suggests consolidation or effusion requiring chest radiograph 2
• Prolonged expiratory phase: Suggests obstructive airway disease 6

Additional Examination Elements

• Allergic facies: Dark infraorbital circles, transverse nasal crease from constant rubbing, Morgan-Dennie lines on lower eyelids 1
• Conjunctival injection or chemosis: Supports allergic etiology 1
• Periorbital edema: May indicate sinusitis complication 1

Diagnostic Approach at 2 Weeks

At exactly 2 weeks, this patient is at the critical decision point: 25% of viral URIs have symptoms persisting to 14 days without bacterial infection, but symptoms persisting beyond 10 days without improvement warrant consideration of bacterial sinusitis or post-viral syndrome 2

When to Suspect Bacterial Sinusitis (Requires ≥3 of 5 Criteria)

• Discolored (purulent) nasal discharge 2
• Severe local facial pain 2
• Fever >38°C 2
• "Double sickening" pattern 2
• Elevated inflammatory markers 2

Common Pitfall to Avoid

Do not diagnose bacterial sinusitis based solely on purulent discharge or sinus symptoms in the first 10 days—87% of patients show sinus abnormalities on CT during viral colds that resolve without antibiotics 2. Antibiotics have no benefit for uncomplicated common cold and contribute to antimicrobial resistance 2.

Initial Diagnostic Testing Indicated

• Chest radiograph: Obtain if hemoptysis, persistent fever, abnormal lung examination, or concern for pneumonia 1, 2, 8, 5
• Spirometry: Consider if wheezing present or concern for asthma/cough-variant asthma 8, 6, 5
• Sinus imaging: NOT indicated at 2 weeks unless severe symptoms or complications suspected 1, 2