Diagnosis: Acute Viral Upper Respiratory Tract Infection (URI)
This patient has a viral upper respiratory tract infection that does not require antibiotics, and treatment should focus on symptomatic relief with first-generation antihistamine/decongestant combination and supportive care. 1, 2
Clinical Reasoning
The symptom constellation—sore throat, productive cough, runny nose, ear pain, and lethargy without fever—is classic for viral URI. 1, 2 The absence of fever is particularly important, as it argues strongly against bacterial complications like acute bacterial rhinosinusitis or pneumonia. 1, 2
Why This Is NOT Bacterial Infection
Antibiotics are not indicated and cause more harm than benefit in this scenario. 2 The patient does not meet criteria for acute bacterial rhinosinusitis, which requires one of three specific patterns: 2
- Symptoms persisting >10 days without improvement
- Severe symptoms (high fever >39°C AND purulent discharge AND facial pain for ≥3 consecutive days)
- "Double sickening" (worsening after initial improvement)
The productive cough with colored sputum does NOT indicate bacterial infection—this simply reflects white blood cells and desquamated epithelium from normal viral inflammation. 1, 2 Acute bronchitis is viral in >90% of cases, and antibiotics are unjustified. 1
Evidence-Based Treatment Plan
First-Line Symptomatic Management
Prescribe a first-generation antihistamine (diphenhydramine or chlorpheniramine) combined with oral decongestant (pseudoephedrine). 3, 1, 2 This combination has the strongest evidence for upper airway cough syndrome and post-viral symptoms. 3, 1
Additional Symptomatic Options
- Dextromethorphan for cough suppression—the most effective over-the-counter option 1, 4
- Saline nasal irrigation provides relief without rebound effects 2
- Intranasal ipratropium bromide if profuse watery rhinorrhea persists 1, 2
- Honey and lemon as home remedy for cough 1
Critical Pitfall to Avoid
Do NOT use topical decongestants (nasal sprays) for more than 3-5 days maximum—this causes rebound congestion. 2 Oral decongestants or saline irrigation are safer alternatives.
Expected Clinical Course
Symptoms typically last 7-10 days but can persist up to 2 weeks. 2 Cough may persist for up to 3 weeks and still be considered normal post-viral progression. 1 Viral shedding peaks in the first 2-3 days and substantially decreases by day 7-10. 3, 2
Red Flags Requiring Re-evaluation
The patient should return immediately if: 1, 2
- Symptoms persist >10 days without improvement
- Symptoms worsen after initial improvement ("double sickening")
- High fever >39°C develops with severe unilateral facial pain
- Shortness of breath or wheezing develops
- Severe headache with neck stiffness, vision changes, or mental status changes
- Hemoptysis occurs
Patient Education
Emphasize hand hygiene as the best prevention strategy. 1 Reassure the patient about the self-limited nature of viral URI—most people expect antibiotics, but the number needed to harm (8) exceeds the number needed to treat (18) for respiratory infections. 3 The colored sputum is normal and does not indicate bacterial infection requiring antibiotics. 1, 2