Pediatric Acute URI Workup Template
History of Present Illness - Key Elements to Document
Focus your HPI on timing and pattern of symptoms to distinguish viral URI from bacterial complications.
Symptom Timeline (Critical for Diagnosis)
- Day of illness onset and current day number—this is the single most important piece of information 1
- Fever pattern: Document if fever occurred early (days 1-2) with constitutional symptoms versus late-onset or persistent fever 1
- Nasal discharge progression: Clear → purulent → clear is typical viral pattern; document current quality and color 1
- Cough characteristics: Daytime versus nighttime predominance, wet versus dry 1
- Symptom trajectory: Improving, stable, or worsening after initial improvement ("double worsening") 1
Constitutional Symptoms
- Fever height and duration (specifically note if ≥39°C/102.2°F) 1
- Headache, myalgias, fatigue—typically resolve within 24-48 hours in viral URI 1
- Appetite and oral intake status 2
- Activity level compared to baseline 2
Red Flag Symptoms to Specifically Ask About
- Duration >10 days without any improvement 1, 2
- Concurrent high fever (≥39°C) AND purulent nasal discharge for ≥3 consecutive days 1
- Worsening after initial improvement 1, 2
- Respiratory distress signs (work of breathing, retractions) 2
- Severe headache or facial pain 1
Past Medical History Essentials
- History of recurrent sinusitis 2
- Atopic conditions: eczema, asthma, allergic rhinitis 1
- Daycare attendance (may have protracted symptoms up to 15 days) 2
- Recent sick contacts 3
- Immunization status 2
Physical Examination - Focused Findings
Vital Signs
- Temperature: Specifically document if ≥39°C 1
- Respiratory rate and work of breathing 2
- Oxygen saturation if respiratory symptoms present 2
General Appearance
- Ill-appearing versus well-appearing—critical distinction for severe onset bacterial sinusitis 1
- Activity level and interaction 1
HEENT Examination
- Nasal examination: Quality of discharge (clear, mucoid, purulent), turbinate erythema/swelling (nonspecific finding) 1
- Sinus percussion: Not useful, do not perform 1
- Allergic stigmata: Nasal crease, allergic shiners, pale nasal mucosa, cobblestoning of conjunctiva or pharynx 1
- Pharynx: Erythema, exudate, tonsillar enlargement 4
- Tympanic membranes: Assess for otitis media complication 5
Respiratory Examination
- Auscultation for wheezing, crackles, or decreased breath sounds 4
- Signs of increased work of breathing 2
Diagnostic Criteria for Bacterial Sinusitis
Make a presumptive diagnosis of acute bacterial sinusitis requiring antibiotics when ANY of the following are present: 1
- Persistent illness: Nasal discharge (any quality) OR daytime cough lasting >10 days without improvement
- Worsening course: New or worsening nasal discharge, cough, or fever after initial improvement
- Severe onset: Concurrent fever ≥39°C AND purulent nasal discharge for ≥3 consecutive days
Diagnostic Testing
Do NOT obtain imaging studies (plain films, CT, MRI, ultrasound) to distinguish bacterial sinusitis from viral URI 1
Management Algorithm
For Uncomplicated Viral URI (Most Cases)
Antibiotics provide no benefit and should NOT be prescribed for viral URI 2, 4, 6
Supportive care only:
- Adequate hydration 2
- Age-appropriate antipyretics (acetaminophen or ibuprofen) for fever/discomfort 2, 4
- Saline nasal irrigation for symptom relief 2
- Rest and comfortable humidity 2
- Avoid decongestants and antihistamines in children <3 years due to adverse effects 2
Expected Course to Counsel Families
- Total duration: 5-7 days typical 1, 2
- Symptoms peak days 3-6 1, 3
- Fever/constitutional symptoms resolve within 24-48 hours 1, 3
- Nasal discharge may become purulent mid-illness then clear—this is normal 1
- Some children have symptoms persisting after day 10 (especially daycare attendees) 2
When to Return for Re-evaluation
- Symptoms persist >10 days without improvement 1, 2
- Worsening after initial improvement 1, 2
- High fever >3 days 2
- Severe onset: fever ≥39°C with purulent discharge for 3-4 days 1
- Signs of respiratory distress 2
Critical Pitfalls to Avoid
- Do not prescribe antibiotics based on purulent nasal discharge alone—this commonly occurs in viral URI and does not indicate bacterial infection 1, 2
- Do not use nasal discharge color to distinguish viral from bacterial infection 1, 2
- Do not obtain imaging to make the diagnosis—clinical criteria are sufficient 1
- Do not rely on physical examination findings (turbinate swelling, sinus percussion)—these are not helpful 1
- Recognize that unnecessary antibiotics increase resistance, C. difficile risk, and provide no clinical benefit 2, 6