What is the likely diagnosis and management for a 25-year-old female with no chronic medical conditions, who presents with fever, sore throat, difficulty swallowing, chills, body aches, and production of green mucus after being exposed to someone in an enclosed car, with minimal improvement on Biogesic (acetaminophen) and slight improvement on Decolgen (pseudoephedrine)?

Likely Diagnosis: Acute Viral Upper Respiratory Tract Infection

This is almost certainly a viral upper respiratory tract infection (URI) and does not require antibiotics. The combination of fever, sore throat, body aches, chills, and productive green mucus following close exposure in an enclosed space, with gradual symptom onset and minimal response to acetaminophen alone, is classic for viral URI 1, 2.

Key Clinical Questions to Ask

Symptom Timeline and Characteristics:

• How many days have symptoms been present? (Viral URIs typically peak at days 3-6 and resolve within 5-7 days, though cough may persist up to 3 weeks) 1
• Did the sore throat start suddenly as the PRIMARY complaint, or did it develop gradually after other symptoms? (Sudden-onset severe sore throat suggests bacterial pharyngitis, while gradual onset with multiple URI symptoms suggests viral etiology) 2
• Is there cough present? (Cough strongly suggests viral rather than streptococcal infection and argues against testing for Group A Streptococcus) 3, 1
• Any nasal congestion or runny nose? (Highly suggestive of viral origin and uncommon in bacterial pharyngitis) 2

Red Flag Symptoms:

• Any difficulty breathing, shortness of breath, or chest pain? (Would suggest pneumonia or more serious infection) 3, 1
• Can you swallow liquids normally, or is there drooling or severe difficulty swallowing? (Severe dysphagia, drooling, or neck swelling suggests peritonsillar abscess, parapharyngeal abscess, or Lemierre syndrome requiring urgent evaluation) 3, 1
• Has fever persisted more than 4 days? (Persistent fever >4 days warrants reassessment for pneumonia or bacterial complications) 3, 1

Examination Findings to Document:

• Are there tonsillar exudates or swollen tonsils? (Exudates suggest possible bacterial pharyngitis requiring testing) 3
• Are there tender anterior cervical lymph nodes? (Part of Centor criteria for bacterial pharyngitis) 3
• What is the fever pattern? (High persistent fever suggests bacterial infection) 3

Differential Diagnoses

Most Likely: Viral Upper Respiratory Tract Infection (70% of acute cough presentations)

• Supports: Gradual onset, multiple URI symptoms (fever, sore throat, body aches, productive cough), exposure history, minimal response to acetaminophen alone 1, 2
• The green mucus does NOT indicate bacterial infection—nasal discharge commonly transitions from clear to purulent and back to clear during uncomplicated viral URIs without antibiotics 2

Less Likely: Influenza

• Consider if: Sudden onset of high fever with severe myalgias and constitutional symptoms, particularly during flu season 3, 2
• The gradual symptom onset and prominent sore throat make this less likely 2

Unlikely: Group A Streptococcal Pharyngitis

• Would require: Sudden-onset severe sore throat as PRIMARY complaint, fever, tonsillar exudates, tender anterior cervical adenopathy, and ABSENCE of cough 3, 1
• This patient has cough (green mucus production), which strongly argues against streptococcal infection 3, 1
• Modified Centor score likely ≤2 (no testing indicated) 3

Very Unlikely: Pneumonia

• Would require: New focal chest signs on examination, dyspnea/tachypnea, OR fever persisting >4 days with abnormal vital signs 3, 1
• No chest radiograph is indicated unless these features are present 1

Management Plan

Do NOT prescribe antibiotics 3, 1

• Multiple randomized placebo-controlled trials consistently demonstrate that antibiotics do not reduce symptom duration or severity in uncomplicated acute bronchitis or viral pharyngitis 3, 1
• Antibiotics are indicated ONLY if Group A Streptococcus is confirmed by testing, which is not warranted here given the presence of cough 3, 1

Symptomatic Treatment (First-Line):

• Acetaminophen or NSAIDs (ibuprofen) for fever, sore throat, and body aches 3, 1
• Throat lozenges for temporary symptomatic relief of sore throat 3, 1
• Warm salt water gargles for throat pain 3, 1
• Adequate hydration 1
• Nasal decongestants (pseudoephedrine, phenylephrine) if nasal congestion is prominent 3, 1

For Cough Management:

• Inhaled ipratropium bromide is the first-line cough suppressant (Grade A recommendation from American College of Chest Physicians) 1
• Dextromethorphan or codeine may provide symptomatic relief, though data are limited 3
• Note: β-agonists have NOT been shown to benefit patients without asthma or COPD 3

Combination Products:

• First-generation antihistamine plus decongestant (e.g., dexbrompheniramine 6 mg + pseudoephedrine 120 mg twice daily) has been shown effective in randomized controlled trials for post-viral URI symptoms 3
• The older-generation antihistamines work via anticholinergic properties to reduce secretions 3
• Decolgen (which contains phenylpropanolamine, chlorpheniramine, and paracetamol) provides some symptomatic relief but does not shorten illness duration 3

Follow-Up and Red Flags

Expected Course:

• Symptoms typically peak at days 3-6 and should begin improving thereafter 1
• Most uncomplicated viral URIs resolve within 5-7 days, though cough may persist for up to 3 weeks (post-infectious cough) 1

Return Immediately If:

• Symptoms persist >10 days without ANY improvement 1, 2
• Symptoms worsen after initial improvement (suggests bacterial superinfection) 1, 2
• High fever persists >4 days 3, 1
• Development of difficulty swallowing, drooling, neck tenderness, or neck swelling (suggests peritonsillar abscess, parapharyngeal abscess, epiglottitis, or Lemierre syndrome) 3, 1
• Development of shortness of breath, chest pain, or focal chest findings (suggests pneumonia) 3, 1

Common Pitfalls to Avoid

Do not prescribe antibiotics based on green mucus alone 2

• Purulent nasal discharge does NOT indicate bacterial infection and is a normal part of viral URI evolution 2

Do not test for Group A Streptococcus if cough is present 3, 1

• The presence of cough strongly suggests viral etiology and testing is not indicated 3, 1

Do not order chest X-ray unless pneumonia is suspected 1

• Chest radiograph is indicated ONLY if there are new focal chest signs, dyspnea/tachypnea, or fever >4 days 3, 1

Recognize that minimal response to acetaminophen alone is expected 3, 1

• Viral URIs require combination symptomatic therapy, not just antipyretics 1