What is the appropriate management for a patient presenting with cold symptoms, considering their history of present illness (HPI), underlying medical conditions, and age?

Essential HPI Questions for Cold Symptoms

When evaluating a patient with cold symptoms, your history should focus on identifying red flags requiring urgent intervention, determining symptom severity to guide treatment selection, and establishing the timeline to differentiate viral illness from bacterial complications.

Critical Red Flag Questions (Require Immediate Action)

• Any hemoptysis? Even small amounts warrant chest radiograph and possible bronchoscopy 1
• Fever >38°C (100.4°F) persisting beyond 3 days OR appearing after initial improvement? This "double sickening" pattern suggests bacterial superinfection 2, 1
• Severe unilateral facial pain with purulent discharge? May indicate bacterial sinusitis, though this is rare before 10 days of symptoms 2, 1
• Acute breathlessness or difficulty breathing at rest? Requires assessment for asthma exacerbation, pneumonia, or anaphylaxis 2
• Drowsiness, disorientation, or confusion? Indicates severe illness requiring urgent evaluation 2
• Coughing up bloody sputum? Mandates immediate chest imaging 2

Symptom Timeline and Pattern

• Day of symptom onset? Critical for zinc supplementation (only effective if started within 24 hours) and antiviral consideration 1, 3, 4
• Current day of illness? Normal viral colds last 7-10 days, with 25% lasting up to 14 days—symptoms persisting beyond 10 days without ANY improvement classify as post-viral rhinosinusitis 1, 3, 5
• Pattern of illness progression? Initial improvement followed by worsening ("double sickening") strongly suggests bacterial complication 2, 1
• Any improvement after 48 hours if already on antivirals? Lack of improvement warrants reassessment 2

Specific Symptom Characterization

• Which symptom is MOST bothersome? This determines whether to use single-agent therapy or combination products 1, 4, 6

  • Nasal congestion alone → oral/topical decongestant 1, 4
  • Rhinorrhea alone → ipratropium bromide nasal spray 1, 3, 4
  • Multiple symptoms → combination antihistamine-decongestant-analgesic product 1, 3, 4

• Presence of purulent (colored) nasal discharge? This is NORMAL in viral colds and does NOT indicate bacterial infection unless accompanied by other criteria 2, 1, 5

• Headache, ear pain, muscle/joint pain, or malaise? NSAIDs (ibuprofen 400-800 mg every 6-8 hours) are specifically effective for these symptoms 1, 3, 7

• Cough characteristics? Acute cough in common cold responds to dextromethorphan (60 mg for maximum effect, though standard OTC doses are subtherapeutic) or menthol inhalation 1, 8

High-Risk Patient Identification

• Age <1 year OR >65 years? Requires closer monitoring and consideration of face-to-face evaluation 2, 3

• Underlying conditions? Specifically ask about:

  • Chronic lung disease (COPD, asthma) 2
  • Heart disease 2
  • Immunocompromised state 2
  • Renal impairment (affects drug clearance in elderly) 3
  • Pregnancy status (NSAIDs contraindicated after 30 weeks) 7

• Current medications? Critical for identifying interactions with cold medications:

  • Anticoagulants (increased bleeding risk with NSAIDs) 7
  • Corticosteroids (increased GI bleeding risk with NSAIDs) 7
  • SSRIs/SNRIs (increased bleeding risk with NSAIDs) 7
  • Antihypertensives (may be affected by decongestants) 7

Bacterial Complication Screening

Only suspect bacterial sinusitis if at least 3 of these 5 criteria are present 1:

1. Discolored (purulent) nasal discharge
2. Severe localized facial pain
3. Fever >38°C (100.4°F)
4. "Double sickening" pattern
5. Elevated inflammatory markers (if obtained)

Common pitfall: 87% of patients show sinus abnormalities on CT during viral colds that resolve without antibiotics—do NOT diagnose bacterial sinusitis in the first 10 days 1

Medication History and Expectations

• What treatments have you already tried? Identifies failed therapies and potential medication overuse (especially topical decongestants >3-5 days causing rebound congestion) 1, 4

• Patient expectations about antibiotics? Address immediately that antibiotics have NO benefit for viral colds and cause significant adverse effects 1, 3, 4, 9

• Previous adverse reactions to cold medications? Particularly antihistamines (sedation, confusion in elderly), decongestants (hypertension, tachycardia), or NSAIDs (GI bleeding, renal impairment) 3, 7

Pediatric-Specific Questions (if applicable)

• Age <4 years? Over-the-counter cough and cold medications should NOT be used due to potential harm without benefit 9, 10

• Age ≥1 year with cough? Honey is safe and effective 1, 10

• Aspirin use? Absolutely contraindicated in children <16 years due to Reye's syndrome risk 2

Social and Exposure History

• Smoking or alcohol use? Both increase risk of complications and GI bleeding with NSAIDs 7

• Ability to perform usual activities? Helps gauge severity and need for work/school excuse 2

• Household contacts with similar illness? Supports viral etiology 5