What is the diagnosis and treatment for a 4-year-old male with fever, cough, cold, green phlegm, and tight airways?

Diagnosis and Treatment for 4-Year-Old with Acute Respiratory Infection

This 4-year-old male has an acute viral upper respiratory tract infection (URTI) and does not require antibiotics. 1, 2

Medical Assessment/Diagnosis

Acute Viral Upper Respiratory Tract Infection (Acute Viral URI)

Clinical Reasoning:

• Fever, cough, rhinorrhea (sipon), and green phlegm in a 4-year-old are most commonly viral in origin 1, 2
• The presence of nasal congestion is highly suggestive of viral etiology 3
• Green/purulent nasal discharge alone does NOT indicate bacterial infection—nasal discharge commonly transitions from clear to purulent and back to clear during uncomplicated viral URIs without antibiotics 3
• "Tight airways" with cough and phlegm production is consistent with viral bronchitis, which is self-limited 4
• No antibiotics are indicated unless specific criteria for bacterial sinusitis are met: persistent symptoms >10 days without improvement, worsening symptoms after initial improvement, or severe presentation with fever ≥39°C and purulent discharge for ≥3 consecutive days 5, 1
• This patient does not meet criteria for acute bacterial sinusitis (symptoms <10 days, no severe presentation described) 5

Important Pitfall to Avoid:

Do not prescribe antibiotics based on green phlegm alone—this is a common misconception. Purulent discharge is normal during viral infections and does not indicate bacterial infection requiring antibiotics. 3, 6

Treatment Plan/Recommendation

Symptomatic Management (PhilHealth Konsulta Formulary):

1. Paracetamol (Acetaminophen) 120mg/5mL suspension

• Dose: 15 mg/kg/dose every 4-6 hours as needed for fever
• For 4-year-old (estimated 16 kg): 10 mL (240 mg) every 4-6 hours as needed
• Dispense: 1 bottle (60 mL)
• Duration: As needed for fever control, typically 3-5 days
• Cost: ~₱25-40 per bottle 2

Alternative if fever persists: Ibuprofen 100mg/5mL suspension

• Dose: 10 mg/kg/dose every 6-8 hours as needed
• For 4-year-old (estimated 16 kg): 8 mL (160 mg) every 6-8 hours as needed
• Dispense: 1 bottle (60 mL)
• Duration: As needed for fever control
• Cost: ~₱50-80 per bottle 2

2. Carbocisteine (Solmux) 250mg/5mL syrup (already being given—continue)

• Dose: 5 mL (250 mg) three times daily
• Dispense: 1 bottle (60 mL)
• Duration: 5-7 days
• Cost: ~₱150-200 per bottle

Total medication cost: ₱175-280 (well within ₱300 budget)

Supportive Care Instructions:

• Ensure adequate fluid intake to maintain hydration 2
• Rest to reduce metabolic demands 2
• Expected course: fever typically settles in 2-4 days, though cough may persist 1-2 weeks 2, 3

Red Flags—Return Immediately If:

• Fever persisting >4-5 days without improvement 2
• Signs of respiratory distress: markedly raised respiratory rate, grunting, intercostal retractions, breathlessness 2
• Inability to take oral fluids or severe dehydration 2
• Drowsiness or behavioral changes 2
• Symptoms worsen after initial improvement 5, 1

Follow-Up:

• Reassess if symptoms worsen or fail to improve within 3-5 days 2
• Monitor for development of bacterial sinusitis criteria (symptoms persisting >10 days) 5

---

Medical Certificate

This certifies that patient has been seen and examined today with the diagnosis of:

Acute Viral Upper Respiratory Tract Infection

and recommendation of:

Home rest for 3-5 days with symptomatic treatment. Patient may return to school when fever-free for 24 hours without antipyretics and feeling well enough to participate in normal activities.

This medical certificate is issued upon the request of the patient for:

School absence/leave due to illness

Note: Patient is NOT yet fit to return to school until fever resolves and child feels well. Expected recovery: 3-5 days for fever, though cough may persist 1-2 weeks. 2, 3