Diagnosis and treatment for pregnant female with viral upper respiratory tract infection symptoms?

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

This patient has a nonspecific viral upper respiratory tract infection that requires only supportive care without antibiotics, as antibiotics do not enhance illness resolution or prevent complications in uncomplicated URTIs. 1

Medical Assessment

Clinical Presentation

• Watery rhinorrhea (sinisipon na parang tubig), headache (masakit ulo), and dizziness (nahilo) are classic symptoms of viral URTI, which is predominantly viral in origin 1
• Purulent nasal discharge does not predict bacterial infection and patients with these symptoms do not benefit from antibiotic treatment 1
• Most cases of uncomplicated URTI resolve spontaneously within 1-2 weeks, with most patients feeling better within the first week 1

Pregnancy Considerations

• No specific modifications to URTI management are required in pregnancy for uncomplicated cases 1
• Screening for asymptomatic infections during pregnancy is not indicated for routine viral URTIs 1

Treatment Plan

Symptomatic Management (No Antibiotics Indicated)

Antibiotic treatment is NOT recommended because it does not enhance illness resolution, decrease duration of symptoms, reduce lost work time, or prevent complications 1

Recommended Medications (PhilHealth Konsulta Formulary-Compliant)

1. Paracetamol 500mg tablets

   • Dose: 500-1000mg every 6 hours as needed for headache and fever
   • Dispense: 20 tablets
   • Duration: 5 days (maximum 4g/24 hours)
   • Safe in pregnancy for pain and fever management 2

2. Cetirizine 10mg tablets (if available as alternative antihistamine)

   • Dose: 10mg once daily for rhinorrhea
   • Dispense: 5 tablets
   • Duration: 5 days
   • Cost-effective option for nasal symptoms 3

Total estimated cost: Under 100 pesos

Non-Pharmacologic Measures

• Adequate hydration and rest 3
• Avoid exposure to irritants 1

Return to Work/School Recommendation

• Patient is fit to return to work/school tomorrow as symptoms are mild and non-debilitating 1
• Most URTIs do not require work absence beyond 1-2 days for symptomatic relief 1

Red Flags Requiring Re-evaluation

• Symptoms persisting beyond 10 days without improvement (suggests possible bacterial sinusitis) 2
• High fever >39°C, severe headache, or respiratory distress (requires immediate reassessment) 4
• Worsening symptoms after initial improvement (consider bacterial superinfection) 2

Patient Education

• This is a viral infection that will resolve on its own within 1-2 weeks 1
• Antibiotics are not needed and will not help viral infections 1, 2
• Symptoms are expected to improve within the first week 1
• Return if symptoms worsen or persist beyond 10 days 2

---

Medical Certificate

This certifies that the patient has been seen and examined today with the diagnosis of: Acute Viral Upper Respiratory Tract Infection (Common Cold)

Recommendation: Symptomatic treatment with paracetamol as needed. Patient is fit to return to work/school. Rest and adequate hydration advised.

This medical certificate is issued upon the request of the patient for: Return to work/school after medical consultation for upper respiratory symptoms.