Diagnosis: Viral Upper Respiratory Tract Infection (Viral URI)
This 13-year-old has a viral upper respiratory tract infection and requires only supportive care—no antibiotics are indicated. 1, 2
Clinical Reasoning
The presentation is classic for viral URI based on several key features:
- Sequential symptom development (GI symptoms → fever/constitutional → respiratory) is characteristic of viral infection, not bacterial pharyngitis 2
- Nasal congestion with productive cough strongly suggests viral rather than bacterial etiology—these features are uncommon in Group A Streptococcus pharyngitis 2
- Symptom duration of approximately 5-6 days falls within the typical 5-7 day course of uncomplicated viral URIs 2
- Nausea and diarrhea as presenting symptoms are common in viral infections, particularly influenza 2
Why This is NOT Bacterial Infection
Bacterial pharyngitis (strep throat) is ruled out because:
- GAS pharyngitis presents with sudden-onset severe sore throat as the PRIMARY complaint, not as part of a constellation of URI symptoms developing over days 2
- The presence of cough, rhinorrhea, and nasal congestion strongly suggests viral rather than bacterial pharyngitis 2
- Testing for GAS is not recommended when clinical features strongly suggest viral etiology (cough, rhinorrhea) 3
Bacterial sinusitis is ruled out because:
- The patient lacks criteria for acute bacterial rhinosinusitis: no high fever ≥39°C with purulent discharge for 3-4 consecutive days, no persistent symptoms ≥10 days without improvement, and no "double-sickening" pattern 3, 2
- Yellow-green mucus alone does NOT indicate bacterial infection—nasal discharge commonly transitions from clear to purulent and back to clear during uncomplicated viral URIs without antibiotics 2
Treatment Plan
Immediate Management
Symptomatic relief only:
- Acetaminophen or NSAIDs for fever, headache, sore throat, and abdominal cramping 3, 1
- Adequate hydration and rest 3, 1
- Throat lozenges and salt water gargles for sore throat 3, 1
- Continue current supportive medications (Robitussin for cough is appropriate) 1
Critical Medication Warning
STOP Benadryl (diphenhydramine) immediately if infectious mononucleosis is suspected. While less likely given the productive cough and nasal congestion, if symptoms persist beyond 2 weeks, avoid amoxicillin or ampicillin as these can cause a characteristic maculopapular rash in 80-90% of patients with EBV infection 1
What NOT to Do
No antibiotics are indicated because:
- This is a viral syndrome where antibiotics provide no benefit and cause harm through adverse effects 1, 2
- Antibiotics should not be prescribed based on sore throat alone without microbiological confirmation 2
- Imaging studies (X-rays, CT scans) are not helpful in distinguishing viral from bacterial infections and are not indicated 2
Expected Course and Return Precautions
Reassure the patient/family:
- Viral pharyngitis symptoms typically last up to 2 weeks with gradual improvement over 1-2 weeks 1
- Fever and constitutional symptoms typically resolve within 24-48 hours, after which respiratory symptoms become more prominent 2
Return immediately if:
- Symptoms persist beyond 10 days without ANY improvement 2
- Symptoms initially improve but then worsen (double-sickening pattern) 2
- High fever develops (≥39°C) with purulent discharge 2
- Severe headache, difficulty breathing, or inability to swallow 1
- Facial swelling or visual changes 2
Consider follow-up testing only if:
- Symptoms persist beyond 2 weeks—consider monospot or EBV serology 1
- Splenomegaly develops on examination 1
Common Pitfalls to Avoid
- Do not prescribe antibiotics for purulent nasal discharge alone—this is a normal progression of viral URIs 2
- Do not order imaging studies for uncomplicated cases—they expose the child to unnecessary radiation and do not distinguish viral from bacterial infection 2
- Do not assume bacterial infection based on symptom duration alone—viral URIs can last up to 10 days 2