What is the best course of action for a 20-year-old patient with mild Upper Respiratory Infection (URI) symptoms, a normal lung exam, but complaining of severe chest burning sensation with breathing?

Management of a 20-Year-Old with Mild URI Symptoms and Severe Chest Burning

This patient requires reassurance and symptomatic management only, as the severe chest burning sensation is most likely musculoskeletal chest wall pain from coughing, not a sign of serious lower respiratory tract disease. The normal lung examination effectively rules out pneumonia or other concerning pulmonary pathology in this young, otherwise healthy patient. 1

Initial Assessment and Red Flag Exclusion

Confirm the absence of serious illness indicators:

• No fever >38°C, no tachypnea (respiratory rate <30/min), no hypoxemia (oxygen saturation ≥92% on room air), and no confusion—these findings exclude severe respiratory infection requiring escalation of care 1
• The normal lung examination (clear breath sounds, no crackles, no bronchial breathing, no dullness to percussion) makes pneumonia highly unlikely 1
• Chest burning with breathing in the context of URI is typically pleuritic-type discomfort from airway inflammation or chest wall muscle strain from coughing, not true pleurisy or cardiac pathology 1

No chest radiograph is indicated in this patient because the clinical presentation does not suggest pneumonia (normal lung exam, young age, mild symptoms) and imaging would not change management 1

Diagnosis

This presentation is consistent with acute viral upper respiratory tract infection (common cold) with associated chest wall discomfort. 2, 3, 4

The three most common causes of cough in patients with normal chest radiographs are upper airway cough syndrome (UACS, formerly post-nasal drip), asthma, and gastroesophageal reflux disease (GERD), but in a 20-year-old with acute URI symptoms lasting days (not weeks), viral URI is the obvious diagnosis. 1

Management Plan

Symptomatic treatment only:

• Advise that most URIs are self-limiting and improve within 7-10 days 2, 5
• For chest burning/discomfort: Recommend acetaminophen (paracetamol) for pain relief and any associated fever 1
• For cough (if distressing): Consider over-the-counter cough suppressants or honey; avoid codeine-based products unless cough is severely distressing 1
• Encourage adequate fluid intake (but no more than 2 liters daily) 1
• Controlled breathing techniques and upright positioning may help reduce chest discomfort 1

Antibiotics are NOT indicated:

• Antibiotics should not be used for the common cold, viral URI, or laryngitis 5
• This patient has no evidence of bacterial pharyngitis (would need tonsillar exudate, anterior cervical lymphadenopathy, absence of cough), bacterial sinusitis (would need symptoms >10 days or severe symptoms with purulent nasal discharge and facial pain), or pneumonia 1, 5

Safety Netting Instructions

Provide specific return precautions:

• Return immediately if: severe breathlessness develops, oxygen saturation drops below 92%, confusion occurs, or symptoms suggest sepsis (feeling severely unwell, not responding to verbal stimuli, mottled skin) 1
• Return for reassessment if: fever persists beyond 5 days, symptoms worsen rapidly or significantly, or no improvement occurs after 10-14 days 1, 2
• Symptoms lasting >2-3 weeks would warrant chest radiograph and consideration of alternative diagnoses (UACS, asthma, GERD, or rarely tuberculosis in high-risk populations) 1, 6

Common Pitfalls to Avoid

Do not over-investigate or over-treat:

• Chest X-rays in young patients with normal lung exams and mild URI symptoms have extremely low yield and expose patients to unnecessary radiation 1
• Empiric antibiotic prescribing for viral URI contributes to antibiotic resistance, causes adverse effects, and provides no benefit 5
• The "severe" nature of the chest burning does not indicate severity of illness—it reflects the patient's subjective experience of discomfort, which is common with viral URI and coughing 1

Recognize that chest burning in URI context is benign:

• Chest wall muscle soreness from repeated coughing is extremely common 1
• Tracheobronchial irritation from viral infection causes burning sensation with deep breathing 2, 4
• True pleuritic chest pain (sharp, worse with inspiration, associated with pleural rub) would be concerning, but this is not described and the lung exam is normal 1