What is the diagnosis and treatment for a patient with a cough, sore throat, nasal stuffiness, body aches, green respiratory sputum production, itching ears, but no shortness of breath, wheezing, or fever?

Diagnosis: Acute Viral Upper Respiratory Tract Infection (Common Cold)

This patient has a self-limited viral upper respiratory infection that does not require antibiotics, and treatment should focus on symptomatic relief with analgesics, decongestants, and possibly antitussives. 1

Clinical Reasoning

The constellation of symptoms—cough, sore throat, nasal stuffiness, body aches, and green sputum production—in the absence of fever, shortness of breath, or wheezing strongly indicates a viral upper respiratory tract infection rather than bacterial infection or pneumonia. 1

Why This Is NOT Bacterial

• Green sputum does NOT indicate bacterial infection. Most short-term coughs are viral even when producing colored phlegm, and antibiotics provide no benefit. 1
• Acute bronchitis is viral in >90% of cases, and the widespread use of antibiotics for this condition is unjustified. 1
• The absence of fever >39°C, absence of severe systemic symptoms, and lack of respiratory distress all argue against bacterial pneumonia or acute bacterial rhinosinusitis. 1

Upper Airway Cough Syndrome (UACS) Component

The combination of nasal stuffiness, sore throat, and itching ears suggests an upper airway cough syndrome (previously called post-nasal drip syndrome), which commonly accompanies viral respiratory infections. 1

• Nasal congestion and the sensation of secretions draining into the posterior pharynx are hallmark features of UACS. 1
• Itching ears further support upper airway involvement rather than lower respiratory pathology. 2

Treatment Algorithm

First-Line Symptomatic Management

Analgesics for pain and body aches:

• Acetaminophen, ibuprofen, or naproxen for sore throat and myalgias. 1, 3
• These provide the most reliable symptomatic benefit. 4

For nasal congestion and upper airway symptoms:

• First-generation antihistamine/decongestant combination (e.g., brompheniramine with pseudoephedrine or chlorpheniramine with phenylephrine) is the recommended first-line approach for UACS. 1
• Start with once-daily bedtime dosing for 2-3 days to minimize sedation, then advance to twice daily if tolerated. 5
• Important caveat: Second-generation non-sedating antihistamines are ineffective for acute cough; only first-generation antihistamines with anticholinergic properties work. 6

For cough suppression:

• Dextromethorphan-containing cough remedies may be the most effective over-the-counter option. 1
• Honey and lemon can be recommended as a home remedy. 1
• Menthol lozenges or vapor rubs may provide additional symptomatic relief. 1, 4

Second-Line Options If Cough Persists Beyond 1-2 Weeks

Intranasal ipratropium bromide:

• Consider ipratropium 2-3 puffs four times daily if rhinorrhea and cough persist, as it may attenuate post-infectious cough. 5, 6

Intranasal corticosteroids:

• Add fluticasone or mometasone nasal spray if prominent upper airway symptoms persist beyond one week. 1, 5
• A 1-month trial of topical corticosteroid is recommended when upper airway symptoms are prominent. 1

What NOT to Do

Do NOT prescribe antibiotics:

• Antibiotics are not indicated and should not be offered for acute bronchitis or viral upper respiratory infections. 1
• Even with green sputum production, antibiotics provide no benefit and cause unnecessary adverse effects. 1
• Routine antibiotic treatment for acute bronchitis should be vigorously curtailed. 1

Avoid topical nasal decongestant sprays:

• Do not use nasal decongestant sprays for more than 3-5 days due to rebound congestion risk. 5

Do NOT use expectorants:

• There is no role for expectorant therapy in acute bronchitis despite sputum production. 1

Expected Clinical Course

• Typical duration of viral upper respiratory infection symptoms is less than 1 week, though cough may persist for up to 3 weeks. 1
• Most episodes of acute rhinosinusitis resolve within a week, with symptom duration ranging from 1 to 33 days. 1
• Patients should be reassured about the self-limited nature of the illness. 1, 4

Red Flags Requiring Further Evaluation

The patient should return for re-evaluation if: 1

• Cough persists beyond 3 weeks
• Fever develops or becomes prolonged
• Shortness of breath or wheezing develops
• Hemoptysis occurs
• Symptoms worsen after initial improvement ("double sickening" suggesting bacterial superinfection)

When to Consider Alternative Diagnoses

If cough persists beyond 3 weeks despite symptomatic treatment, consider:

• Post-infectious cough/subacute cough (3-8 weeks duration) may require inhaled ipratropium or short course of inhaled corticosteroids. 5, 6
• Pertussis if paroxysmal cough with post-tussive vomiting or inspiratory whoop develops (though unlikely given current presentation). 1, 6
• Asthma or GERD if cough becomes chronic (>8 weeks). 1, 7

Prevention and Patient Education

• Emphasize hand hygiene as the best way to prevent transmission of cold viruses. 1, 4
• Advise using handkerchief and washing hands to avoid spreading infection. 1
• Smoking cessation counseling if applicable, as smoking worsens respiratory symptoms. 1