Management of Acute Upper Respiratory Symptoms in an Adolescent with Well-Controlled Asthma
This patient requires symptomatic treatment only for a self-limiting viral upper respiratory infection, with no indication for antibiotics, and reassurance that the A1c of 5.8% definitively rules out diabetes.
Sore Throat and Upper Respiratory Symptoms Management
The clinical presentation of sore throat with nasal congestion, nonproductive cough, and purulent nasal discharge in a 13-year-old is consistent with a viral upper respiratory infection that will resolve spontaneously within 7 days without antibiotics. 1
Symptomatic Treatment Approach
Recommend ibuprofen or naproxen for pain control of the sore throat, as these are evidence-based first-line symptomatic treatments. 1
Encourage self-management with adequate hydration and rest, as acute sore throat is typically self-limiting with a mean duration of 7 days. 1
Approve the requested refills for cetirizine and montelukast (Singulair) to manage the nasal congestion and maintain asthma control. 2
Antibiotic Decision-Making
Antibiotics are not indicated in this case, as the patient lacks red-flag symptoms (no immunosuppression, no severe systemic infection signs) and the clinical picture suggests viral etiology. 1
Even if bacterial pharyngitis were considered, clinical scoring systems (Centor, McIsaac, FeverPAIN) would be needed, and scores suggesting bacterial cause still show only modest benefit from antibiotics. 1, 3
The purulent nasal discharge does not indicate bacterial infection requiring antibiotics, as this is a common feature of viral upper respiratory infections. 3
Asthma Management Considerations
The patient's asthma is well-controlled on Advair with no albuterol use for 3 weeks and no current respiratory distress, requiring no acute intervention. 2
Key Asthma Safety Points
Monitor for any signs of acute asthma exacerbation during this respiratory infection, including inability to complete sentences, pulse >110 bpm, respirations >25 breaths/min, or diminished breath sounds. 4
The patient does not meet criteria for acute severe asthma, as there is no shortness of breath, normal respiratory effort, and well-controlled baseline asthma. 4
The 3-month follow-up plan is appropriate given the absence of symptoms and good control, rather than unnecessary weekly visits. 5
Important Caveat for Asthma Patients
Patients with asthma history should not receive live attenuated intranasal influenza vaccine (LAIV) if they require vaccination, as the safety in asthma patients has not been firmly established. 5
Inactivated influenza vaccine (IIV) is the appropriate choice for this patient with asthma history if seasonal vaccination is needed. 5
Diabetes Evaluation
The A1c of 5.8% and fasting glucose of 90-92 mg/dL definitively exclude diabetes and even prediabetes, providing complete reassurance to the family.
Interpretation of Results
Normal A1c is <5.7%, and this patient's value of 5.8% is only minimally elevated and does not meet criteria for prediabetes (5.7-6.4%) or diabetes (≥6.5%). 6
The fasting glucose of 90-92 mg/dL is completely normal (normal range 70-99 mg/dL), well below the prediabetes threshold of 100-125 mg/dL.
The symptoms of increased hunger, thirst, and urination for 4 months are not explained by diabetes given these normal laboratory values, and likely represent normal adolescent growth patterns or behavioral factors.
Clinical Context
No further diabetes testing is needed at this time, as both screening tests are reassuring. 6
The BUN/creatinine ratio of 26 (slightly elevated) likely reflects mild dehydration from the acute illness and increased oral intake, not renal pathology, given the normal creatinine of 0.53 mg/dL.
Reassure the family that despite the paternal history of diabetes, the current laboratory values provide strong evidence against diabetes or prediabetes.
Expected Clinical Course
The patient should experience improvement within 24-48 hours with symptomatic treatment, and complete resolution within 7 days. 1