What is the likely diagnosis and treatment for a [AGE]-year-old male patient (Pt) presenting with a scratchy throat, cough, sore throat, ear pain (both ears), and left shoulder blade pain that worsens with movement?

Likely Diagnosis: Viral Upper Respiratory Tract Infection (Common Cold) with Acute Bronchitis

This patient has a viral upper respiratory tract infection (common cold) with acute bronchitis, and antibiotics are explicitly contraindicated. 1, 2

Clinical Reasoning

The constellation of scratchy throat, cough, sore throat, bilateral ear pain, and absence of high fever or systemic illness is classic for viral URI. 3 The key diagnostic features include:

• Bilateral ear fullness/pain suggests Eustachian tube dysfunction from viral inflammation, not bacterial otitis media 3
• Sore throat with cough in the absence of high fever, tonsillar exudates, or tender anterior cervical adenopathy makes bacterial pharyngitis (Group A Streptococcus) unlikely 3
• Scratchy throat and cough represent typical viral URI symptoms that commonly persist 6-15 days 3

The left shoulder blade pain with movement is most likely musculoskeletal from excessive coughing, which causes strain on intercostal and periscapular muscles. 4 This referred pain pattern is common with persistent cough and does not suggest pneumonia in the absence of fever, tachypnea, tachycardia, or focal chest findings. 1

What to Rule Out First

Exclude pneumonia by checking vital signs for tachycardia (>100 bpm), tachypnea (>20 breaths/min), and fever with systemic illness. 1 Perform chest examination for dullness to percussion, bronchial breath sounds, or crackles. 1 If these findings are absent, chest X-ray is not indicated. 1

Assess for Group A Streptococcal pharyngitis using modified Centor criteria: fever by history, tonsillar exudates, tender anterior cervical adenopathy, and absence of cough. 3 If fewer than 3 criteria are present, testing is not warranted. 3 This patient likely has cough, making strep throat unlikely.

Treatment Plan

What NOT to Do (Critical)

• Do NOT prescribe antibiotics (amoxicillin, azithromycin, etc.) for viral URI or acute bronchitis—they provide no benefit, contribute to antimicrobial resistance, and cause adverse effects including allergic reactions and C. difficile infection. 1, 2, 5
• Do NOT use nasal decongestant sprays beyond 3-5 days due to rebound congestion risk. 1

Recommended Treatment

Symptomatic relief for cough and throat:

• Honey and lemon as initial home remedy—cost-effective with no adverse effects 1
• Guaifenesin 200-400 mg every 4 hours (up to 6 times daily) to help loosen phlegm and thin bronchial secretions 1, 2
• Dextromethorphan for dry, bothersome cough, especially at night 1, 6

For bilateral ear fullness/pain:

• First-generation antihistamine-decongestant combination (brompheniramine/pseudoephedrine or chlorpheniramine/phenylephrine) to reduce Eustachian tube congestion 2, 5

For musculoskeletal shoulder blade pain:

• NSAIDs (ibuprofen 400-600 mg every 6-8 hours as needed) for pain relief
• Reassure that this is from cough-related muscle strain

If wheezing is present on exam:

• Bronchodilator treatment is required—transient wheezing that clears with coughing may not need long-term therapy 1

Expected Timeline and Follow-Up

• Cough should be worst in first few days and gradually improve over 1-2 weeks 1
• Sore throat and ear pain typically resolve within 5-7 days 3
• Re-evaluate if symptoms worsen after initial improvement or persist beyond 2-3 weeks without constant improvement 1, 2

When to Consider Further Intervention

If cough persists ≥3 weeks but <8 weeks (post-infectious cough):

• Consider inhaled ipratropium bromide 2-3 puffs four times daily if quality of life is significantly affected 1, 2
• Inhaled corticosteroids may be considered after ipratropium if symptoms persist 2

Red flags requiring urgent re-evaluation:

• Development of fever after initial improvement 2
• Hemoptysis 2
• Severe dyspnea or chest pain 1
• Inability to swallow or drooling (suggests peritonsillar abscess or epiglottitis) 3

Special Consideration: Pertussis

Suspect pertussis if: paroxysmal cough with post-tussive vomiting or "whooping" sound develops, even in vaccinated patients. 1, 5 If suspected, obtain nasopharyngeal swab for culture and start macrolides (azithromycin or clarithromycin). 1