What is the appropriate evaluation and management plan for a patient presenting with an upper respiratory infection (URI), including history of present illness (HPI), review of systems (ROS), physical examination (PE), assessment, and treatment options, considering potential diagnoses such as viral upper respiratory infection, bacterial pharyngitis, sinusitis, or bronchitis?

Evaluation and Management of Upper Respiratory Infections

History of Present Illness (HPI)

Document the precise duration and pattern of symptoms, as this is the single most critical factor in distinguishing viral from bacterial infection. 1

Essential Timeline Questions

• Symptom duration: Specifically ask if symptoms have persisted beyond 10 days without improvement—this is the threshold where bacterial infection likelihood increases to approximately 60% 1, 2
• Pattern of illness: Ask specifically about "double worsening"—initial improvement followed by worsening within 10 days, which is highly suggestive of secondary bacterial infection 1, 2
• Severity criteria: Document if fever ≥39°C (102.2°F) with purulent nasal discharge or facial pain for ≥3 consecutive days 1, 2

Cardinal Symptoms to Document

• Purulent nasal drainage: Specifically ask about colored (cloudy, yellow, or green) anterior or posterior nasal discharge 1
• Facial pain/pressure/fullness: Document location (anterior face, periorbital, maxillary/dental areas) and whether it's unilateral or bilateral 1
• Nasal obstruction: Ask about congestion, blockage, or stuffiness 1

Additional Symptoms

• Cough (note that this can persist in 40% of patients at 10 days as part of normal viral resolution) 2
• Headache 1
• Hyposmia or anosmia 1
• Ear pressure or fullness 1
• Fever 1
• Fatigue/malaise 1
• Halitosis 1
• Sore throat 1

Critical Red Flags to Screen For

• Orbital symptoms: Periorbital swelling, redness, edema, or vision changes 2
• Neurological symptoms: Severe headache, altered mental status, or focal neurological deficits 2
• Severe facial swelling or erythema over involved sinus 2

Review of Systems (ROS)

Respiratory

• Shortness of breath or wheezing (to assess for asthma comorbidity) 1
• Chest pain or tightness 1

HEENT

• Vision changes or eye pain (orbital complications) 2
• Dental pain (maxillary sinusitis) 1
• Hearing changes or ear pain 1

Constitutional

• Fever pattern and maximum temperature 1
• Chills, night sweats 1
• Fatigue severity 1

Immunologic

• History of recurrent infections (screen for immunodeficiency) 1
• Known allergic rhinitis 1

Physical Examination (PE)

A focused examination targeting specific findings is more valuable than a comprehensive examination for URI. 3

Vital Signs

• Temperature: Fever ≥39°C increases likelihood of bacterial infection 1
• Blood pressure, heart rate, respiratory rate 4

Head and Neck Examination

External Inspection

• Facial swelling or erythema: Particularly over maxillary or frontal sinuses 2
• Periorbital examination: Look for edema, erythema, or proptosis (orbital complications) 2

Nasal Examination

• Anterior rhinoscopy using nasal speculum or otoscope with nasal adapter 1
• Document mucosal appearance: Erythema, edema, pallor, or boggy turbinates 1
• Purulent secretions: Presence and location (anterior vs. middle meatus) 1
• Septal deviation or anatomic abnormalities 1
• Nasal polyps: Presence suggests chronic disease or allergic component 1

Sinus Palpation/Percussion

• Maxillary sinus tenderness: Palpate over cheeks 1
• Frontal sinus tenderness: Palpate above eyebrows 1
• Note: Tenderness has limited specificity but supports clinical diagnosis 1

Oropharyngeal Examination

• Pharyngeal erythema or exudates (if sore throat present) 1
• Tonsillar enlargement 1
• Posterior pharyngeal drainage 1

Cervical Lymph Nodes

• Anterior cervical adenopathy (if pharyngitis suspected) 1

Neurological Examination (If Red Flags Present)

• Mental status 2
• Cranial nerve examination (particularly II, III, IV, VI if orbital symptoms) 2

Assessment

Viral Upper Respiratory Infection (Most Common)

Diagnose viral URI when symptoms are present <10 days without worsening. 1, 2

• Most URIs are viral and resolve within 7-10 days 1, 2, 5
• 40-90% of viral URIs show CT evidence of sinus involvement that resolves without antibiotics 1
• Purulent discharge alone does NOT indicate bacterial infection—it occurs normally after a few days due to neutrophil influx 2

Acute Bacterial Rhinosinusitis (ABRS)

Diagnose ABRS when any of these three patterns are present: 1, 2

1. Persistent symptoms ≥10 days without improvement 1, 2
2. Severe symptoms: Fever ≥39°C with purulent discharge or facial pain for ≥3 consecutive days 1, 2
3. Double worsening: Initial improvement followed by worsening within 10 days 1, 2

Note: Fewer than 2% of viral URIs progress to bacterial sinusitis 1

Streptococcal Pharyngitis (If Sore Throat Predominates)

• Requires testing (rapid antigen or culture) for confirmation 1
• Do NOT prescribe antibiotics without positive testing 1

Differential Diagnoses to Consider

• Allergic rhinitis (chronic symptoms, seasonal pattern, pale/boggy turbinates) 1
• Vasomotor rhinitis 1
• Migraine or tension headache (facial pain without purulent discharge) 1
• Dental abscess 1

Plan

For Viral URI (Symptoms <10 Days, Not Worsening)

Provide symptomatic treatment only—antibiotics are NOT indicated and cause more harm than benefit. 1, 2

Symptomatic Management

• Analgesics: Acetaminophen, ibuprofen, or naproxen for pain/fever 1, 6
• Intranasal saline irrigation: Alleviates symptoms 1
• Decongestants/antihistamines: May provide symptom relief (avoid in children <6 years per FDA) 6, 7

Patient Education

• Typical viral URI resolves within 7-10 days 2, 5
• Cough and nasal discharge can persist in 40% at 10 days as normal viral resolution 2
• Colored nasal discharge alone does NOT mean bacterial infection 2
• Return if: Symptoms persist beyond 10 days, worsen after initial improvement, or develop high fever with severe facial pain 2

Follow-Up

• Reassess if symptoms persist beyond 10 days or worsen 1, 2

For Acute Bacterial Rhinosinusitis (ABRS)

Two evidence-based approaches exist with different recommendations from major societies: 1

Option 1: Watchful Waiting (American Academy of Otolaryngology Recommendation)

• Preferred initial approach for uncomplicated ABRS regardless of severity 1
• Continue symptomatic treatment as above 1
• Intranasal corticosteroids may decrease antibiotic need 1
• Reassess in 7 days 1
• Prescribe antibiotics only if no improvement or worsening 1

Option 2: Immediate Antibiotics (IDSA Recommendation)

• Amoxicillin-clavulanate is the preferred agent 1, 8
• Alternative: Doxycycline or respiratory fluoroquinolone (if penicillin allergy) 1
• Note: Some societies recommend amoxicillin alone as first-line, though IDSA prefers amoxicillin-clavulanate for resistance coverage 1

Clinical Context: Number needed to treat with antibiotics is 18 for rapid cure, but number needed to harm from adverse effects is 8 1. This supports watchful waiting as the preferred initial strategy for most patients.

Adjunctive Therapy

• Intranasal saline irrigation 1
• Intranasal corticosteroids 1
• Analgesics for pain 1

Imaging

Do NOT order routine imaging (X-ray or CT) for uncomplicated URI or sinusitis. 1, 2

• Imaging cannot distinguish viral from bacterial infection 1, 2
• Increases costs 4-fold without improving outcomes 1
• Contrast-enhanced CT indicated ONLY if complications suspected (orbital or CNS involvement) 2

Specialist Referral Indications

• Seriously ill appearance 1
• Clinical deterioration despite antibiotic therapy 1
• Recurrent episodes 1
• Signs of complications (orbital, neurological) 2
• Consider evaluation for underlying allergic rhinitis if recurrent sinusitis 1

Red Flag Management

Immediate evaluation required for: 2

• Orbital symptoms (periorbital swelling, vision changes, proptosis) 2
• Severe headache with altered mental status 2
• Neurological symptoms 2
• Facial swelling/erythema with severe pain 2

These patients require urgent imaging and likely hospital admission for IV antibiotics and possible surgical intervention 2.