Diagnosis and Management
Most Likely Diagnosis
This patient has acute viral nasopharyngitis (common cold) that is resolving appropriately, with no indication for antibiotics at this time. 1
The clinical presentation—2 days of fever, white nasal discharge transitioning to thick green phlegm, headache, sore throat, and swollen non-erythematous turbinates—is classic for viral upper respiratory infection. 1 Importantly, symptoms have already improved significantly after only 2 days, with fever and most symptoms resolved except productive cough. 1
Why This Is NOT Bacterial Sinusitis
Patients with symptoms for fewer than 7 days are unlikely to have bacterial infection and do not require antibiotics. 1 The key diagnostic criteria for acute bacterial rhinosinusitis (ABRS) require:
- Duration ≥10 days without improvement, OR 2, 3
- Severe symptoms (high fever ≥39°C with purulent discharge for ≥3-4 consecutive days), OR 1
- "Double worsening" (initial improvement followed by worsening within 10 days) 2, 3
This patient meets none of these criteria—she is only on day 2 and already improving. 1
Critical Point About Green/Purulent Discharge
Do not prescribe antibiotics based on purulent nasal discharge alone—this is a normal feature of viral colds. 1 Secretions naturally become thicker and colored (yellow-green) after a few days in viral infections, then clear before resolution. 2 This color change reflects neutrophil activity, not bacterial infection. 2
Recommended Management
Continue Symptomatic Treatment Only
No antibiotics are indicated. 1 The patient should continue:
Acetaminophen or NSAIDs (ibuprofen) for any residual discomfort or fever 1
- Current dosing of 500 mg paracetamol every 4 hours is appropriate 4
Nasal saline irrigation to facilitate clearance of nasal secretions and provide modest symptom relief 1
Short-term nasal decongestant (oxymetazoline) if severe nasal congestion develops, but strictly limit to 3 days maximum to avoid rhinitis medicamentosa 3
What NOT to Do
Avoid antihistamines—the presence of rhinorrhea and cough strongly suggests viral etiology, and antihistamines provide no benefit in non-allergic viral infections while potentially worsening congestion by thickening secretions. 3
Do not order imaging (CT or plain radiography)—diagnosis is clinical and imaging is not indicated for uncomplicated cases. 3
When to Reassess
Instruct the patient to return if:
- Symptoms persist ≥10 days without improvement 1, 3
- High fever ≥39°C with purulent nasal discharge or facial pain for ≥3-4 consecutive days 1
- Worsening symptoms after initial improvement (double worsening pattern) 1, 3
Any of these would indicate possible progression to ABRS and warrant consideration of antibiotics (amoxicillin as first-line). 3
Patient Education
Reassure the patient that:
- Symptoms typically last up to 2 weeks and are self-limited 1
- The illness resolves without antibiotics, even when bacterial pathogens are present 1
- Persistent productive cough for several days after other symptoms resolve is normal and expected 1
- Hand hygiene is the most effective method to reduce transmission 1
Physical Examination Findings Explained
Swollen non-erythematous turbinates are consistent with viral rhinitis. 2 Red, swollen nasal tissue would suggest infectious rhinitis/sinusitis, while pale boggy turbinates suggest allergic rhinitis—neither applies here. 2 The non-erythematous swelling supports viral inflammation without bacterial superinfection. 2