Diagnosis: Acute Viral Syndrome
Based on the clinical presentation of a 20-year-old male with 2 days of general malaise without specific respiratory or systemic red flags, the most appropriate diagnosis is Acute Viral Syndrome, and he can be cleared to return to work with symptomatic treatment using paracetamol 500mg, 1-2 tablets every 6 hours as needed for fever, dispensing 20 tablets for 5 days. 1
Clinical Assessment
The patient presents with the classic features of acute viral syndrome characterized by:
- Acute onset of systemic symptoms (general malaise/"sumama pakiramdam") 1
- Short duration (2 days) 1
- Absence of severe respiratory symptoms, persistent high fever, or other red flags 1
- Young, otherwise healthy individual 1
This presentation aligns with self-limited viral illness that typically resolves within 3-7 days with supportive care alone. 1
Medical Certificate Documentation
Diagnosis: Acute Viral Syndrome
Recommendation: Fit to return to work with symptomatic treatment. Advised adequate rest, hydration, and monitoring for warning signs.
Purpose: Patient requested medical clearance to return to work after 2-day absence due to illness.
Treatment Plan
Medication (Within PhilHealth Konsulta Budget <300 pesos):
Paracetamol 500mg tablets
- Dosing: 1-2 tablets every 6 hours as needed for fever or body aches 2
- Dispense: 20 tablets 2
- Duration: 5 days (or until symptoms resolve) 2
- Instructions: Take with food, maximum 8 tablets per 24 hours 2
Note: Paracetamol is preferred over ibuprofen for viral syndromes as temperatures below 38°C are acceptable and not all fever requires aggressive suppression. 2
Return Precautions - Red Flags Requiring Immediate Re-evaluation
Instruct patient to return immediately if any of the following develop:
- Recurrence of high-grade fever (>38.5°C) persisting beyond 3 days 1
- Development of significant respiratory symptoms (shortness of breath, chest pain, persistent cough) 1
- Altered mental status or severe headache 1
- Persistent vomiting or inability to maintain hydration 1
- Development of rash or conjunctivitis 1
Clinical Reasoning
The American College of Physicians and CDC define acute viral syndrome by the presence of acute systemic symptoms with absence of severe respiratory or bacterial infection features. 1 At 2 days duration with planned return to work, this patient demonstrates mild, self-limited illness without features requiring further workup or observation. 1
The key clinical decision point is excluding serious bacterial infection or early severe viral pneumonia - this patient lacks fever documentation, respiratory distress, or timeline suggesting progression to complicated disease. 1 The Society of Hospital Medicine emphasizes that supportive care with antipyretics and monitoring for red flags is appropriate management for uncomplicated acute viral syndrome. 1
Common Pitfall to Avoid:
Do not routinely prescribe antibiotics (such as azithromycin) for uncomplicated viral syndrome, as this promotes resistance without clinical benefit. 2 Antibiotics are only indicated if bacterial superinfection develops with appropriate clinical features. 2