What are the common medical treatments for symptomatic control of patients presenting to urgent care with symptoms such as cough, sore throat, shortness of breath, nausea, vomiting, diarrhea, or musculoskeletal injuries?

Symptomatic Management of Common Urgent Care Presentations

Cough

For symptomatic control of cough in urgent care patients, first-generation antihistamine plus decongestant combinations are most effective for viral upper respiratory infections, while opioid-based antitussives (codeine linctus, codeine phosphate, or morphine sulfate oral solution) should be reserved for distressing cough that interferes with daily activities. 1, 2

Treatment Algorithm

• Viral upper respiratory infection (common cold): Combination first-generation antihistamine plus decongestant is the most effective treatment 2
• Distressing cough: Consider short-term use of codeine linctus, codeine phosphate tablets, or morphine sulfate oral solution 1
• Severe or persistent cough: Start with demulcents (butamirate linctus, simple linctus, or glycerin-based linctus) 1
• Opioid-resistant cough: Trial peripherally-acting antitussives (levodropropizine, moguisteine, levocloperastine, or sodium cromoglycate) where available 1
• Refractory cases: Consider nebulized lidocaine/bupivacaine or benzonatate 1

Critical Pitfalls

• Antibiotics are NOT indicated for most cases of acute cough and provide minimal benefit (reducing cough by only half a day) while causing adverse effects including allergic reactions, nausea, vomiting, and Clostridium difficile infection 3
• Avoid lying on the back, as this can worsen cough 1
• Educate patients that acute bronchitis cough typically lasts 2-3 weeks 3

Sore Throat

For sore throat management, avoid antibiotics unless bacterial pharyngitis is confirmed, as most cases are viral and antibiotics provide no benefit while causing unnecessary adverse effects. 3

• Symptomatic relief with acetaminophen or NSAIDs for pain control 1
• Consider throat lozenges or demulcents for local symptom relief 1

Shortness of Breath

Immediate oxygen therapy targeting 88-92% saturation in suspected COPD patients, combined with nebulized bronchodilators (salbutamol 2.5-5 mg or ipratropium 0.25-0.5 mg), represents first-line management while obtaining chest radiography and arterial blood gas measurements. 4

Immediate Assessment

• Perform vital signs: pulse rate, respiratory rate, blood pressure, oxygen saturation 4
• Note signs of respiratory distress: audible wheeze, tachypnea, accessory muscle use, peripheral edema, cyanosis, confusion 4
• Obtain chest radiograph to rule out pneumonia 4, 5
• Measure arterial blood gas tensions 4
• Perform ECG to assess cardiac causes 4

Oxygen Therapy

• For suspected COPD: Initially limit oxygen to 28% via Venturi mask or 2 L/min via nasal cannulae until blood gas results available 4
• Target saturation: 88-92% to prevent hypercapnic respiratory failure 4
• Check blood gases within 60 minutes of starting oxygen 4

Bronchodilator Therapy

• Moderate exacerbations: β-agonist (salbutamol 2.5-5 mg or terbutaline 5-10 mg) OR anticholinergic (ipratropium 0.25-0.5 mg) 4
• Severe exacerbations or poor response: Administer BOTH β-agonist AND anticholinergic 4

Additional Management

• COPD exacerbation: Prednisolone 30 mg/day orally or hydrocortisone 100 mg IV for 7-14 days 4
• Signs of infection (purulent sputum, fever): Initiate antibiotics 4

Critical Pitfalls

• Pneumonia requires urgent assessment with chest imaging, blood cultures, CBC, and inflammatory markers 5
• Do not delay evaluation in patients with fever >103°F and productive cough 5
• Hospitalize if chest imaging shows infiltrates, laboratory reveals leukopenia/neutropenia, or patient shows dehydration, hypotension, or respiratory distress 5

Nausea and Vomiting

Ondansetron 8 mg administered 30 minutes before anticipated nausea triggers or at symptom onset provides effective antiemetic control, with repeat dosing every 8 hours as needed for persistent symptoms. 6

Dosing Regimens

• Initial dose: Ondansetron 8 mg administered 30 minutes before trigger or at symptom onset 6
• Repeat dosing: 8 mg every 8 hours for persistent symptoms 6
• Alternative: Single 24 mg dose may be used, though 8 mg twice daily is equally effective 6

Critical Pitfalls

• Avoid ondansetron 32 mg single dose due to lack of additional efficacy over lower doses 6
• In COVID-19 patients with nausea/vomiting, assess for gastrointestinal manifestations which occur in 1-36% of patients 1

Diarrhea

Symptomatic management of diarrhea focuses on hydration assessment and electrolyte monitoring, with specific attention to COVID-19 as a potential etiology given its gastrointestinal manifestations. 1

• Assess hydration status and check electrolyte profile 5
• COVID-19 causes diarrhea in 1-36% of patients through angiotensin converting enzyme II receptors in gastric, duodenal, and rectal epithelia 1
• Monitor for fever and other systemic symptoms suggesting infection requiring antibiotics 5

Musculoskeletal Injuries

Symptomatic pain control with acetaminophen as first-line therapy (up to 2 grams per dose, not exceeding 4 grams in 24 hours) provides effective analgesia while avoiding NSAID-related complications in patients with renal, cardiac, or gastrointestinal concerns. 1, 7

Pain Management

• First-line: Acetaminophen up to 2 grams per dose, maximum 4 grams in 24 hours 1, 7
• NSAIDs: Avoid in patients with severe systemic illness affecting renal, cardiac, or gastrointestinal systems 7

Critical Pitfalls

• Be cautious with opioid prescriptions due to increased requirements and risk of misuse 7
• Assess for fever and myalgias that may indicate systemic infection rather than isolated musculoskeletal injury 7

General Principles

• Educate patients about expected symptom duration to reduce unnecessary return visits 3
• Implement treatment escalation plans for patients who may deteriorate rapidly 1
• Document advance care plans and do-not-resuscitate decisions when applicable 1
• Provide clear instructions on when to seek further care, such as through NHS 111 online or emergency department 1