What are the next steps for a 33-year-old female patient with a chief complaint of cough, presenting with a 3-day history of dry cough and irritated throat, followed by thick white nasal discharge and ear fullness, with a past medical history of Major Depressive Disorder managed with Vortioxetine (Trintellix), and physical examination findings of faint coarse crackles in the posterior lower lung fields, after a recent trip to the USA?

Next Steps for This Patient

This patient has an acute upper respiratory tract infection with possible early lower respiratory tract involvement, and should receive symptomatic treatment with a first-generation antihistamine/decongestant combination, adequate hydration, and consideration of chest radiography given the lung crackles. 1

Immediate Assessment

Rule out red flags requiring urgent intervention:

• Check vital signs (respiratory rate, oxygen saturation, temperature, heart rate, blood pressure) 2, 1
• The presence of faint coarse crackles in posterior lower lung fields warrants further evaluation, as this may indicate pneumonia or bronchitis 2
• No hemoptysis, weight loss, or severe systemic illness reported, which reduces concern for serious pathology 2

Diagnostic Workup

Obtain a chest radiograph given the physical examination finding of crackles, even if faint, to rule out pneumonia 2. The guideline recommends chest radiography for patients with acute cough and abnormal vital signs or chest examination findings to improve diagnostic accuracy 2. While crackles can occur with viral bronchitis, they may also indicate pneumonic consolidation 2.

If chest X-ray is normal and vital signs are stable, this represents acute viral upper respiratory tract infection with bronchitis 2, 1.

If chest X-ray shows consolidation, diagnose community-acquired pneumonia and initiate empiric antibiotics immediately according to local guidelines 2, 3.

Treatment Plan

For Presumed Viral Upper Respiratory Infection (if X-ray normal):

Initiate first-generation antihistamine/decongestant combination as first-line therapy for the nasal discharge, ear fullness, and throat irritation 2, 1. This addresses the upper airway cough syndrome (formerly postnasal drip syndrome) that is driving her symptoms 2.

Symptomatic relief measures:

• Adequate hydration 1
• Honey for cough suppression (more effective than over-the-counter preparations) 2, 1
• Acetaminophen for fever if present 1
• Simple home remedies like honey and lemon are as effective as commercial preparations 2

Avoid routine antibiotics if no radiographic evidence of pneumonia and vital signs are normal 2, 1.

If Pneumonia is Confirmed:

Start empiric antibiotics immediately - for an otherwise healthy 33-year-old without comorbidities, use either a macrolide (azithromycin or clarithromycin) or doxycycline 3.

Medication Interaction Consideration

Vortioxetine (Trintellix) does not require dose adjustment for acute respiratory infections 4, 5. Continue her psychiatric medication as prescribed, as discontinuation could precipitate depressive relapse 4, 5.

Safety Net Instructions

Return immediately or call if:

• Breathing difficulty develops 1
• Fever persists beyond 3 days 6
• Cough worsens significantly 7

Schedule follow-up if:

• Cough persists beyond 7 days without improvement 2, 7
• New symptoms develop (chest pain, significant dyspnea, hemoptysis) 2

Expected time course: Viral upper respiratory infections typically improve within 3 weeks 2. If cough persists beyond 3 weeks, it transitions to subacute cough requiring re-evaluation for post-infectious cough, asthma, or other causes 2.

Critical Pitfalls to Avoid

Do not dismiss the lung crackles - even faint crackles warrant chest radiography in the setting of acute cough to avoid missing pneumonia 2.

Do not prescribe opiate antitussives (codeine, pholcodine) - they have significant adverse effects without superior efficacy compared to simpler measures 2.

Do not use antibiotics empirically without evidence of bacterial infection - this patient's presentation is most consistent with viral infection unless pneumonia is confirmed radiographically 2, 1.

Monitor for worsening - the recent travel history and 3-day symptom duration place her in the typical window for viral URTI, but progression to bacterial superinfection can occur 2.