What is the most likely diagnosis and recommended management for a 15-year-old male with fever, clear nasal discharge, nasal congestion, temple headache, dizziness, and a single 5‑minute episode of visual dimming triggered by a sudden postural change, who has normal vital signs and an unremarkable physical examination?

Most Likely Diagnosis and Management

This 15-year-old male most likely has an acute viral upper respiratory infection (URI) with orthostatic presyncope, and should be managed with symptomatic treatment including analgesics, nasal decongestants, adequate hydration, and reassurance with clear return precautions. 1

Primary Diagnosis: Acute Viral URI

The clinical presentation strongly supports a viral URI rather than acute bacterial rhinosinusitis (ABRS):

• Symptom duration of only 1 day does not meet criteria for ABRS, which requires either persistent symptoms ≥10 days without improvement, worsening after initial improvement within 5-7 days, or severe onset with high fever (≥39°C) and purulent discharge for ≥3 consecutive days 2, 1
• The patient exhibits classic viral URI symptoms: fever, clear nasal discharge, nasal congestion, and headache—all typical of the early viral phase that peaks between days 3-6 2, 1
• Normal vital signs and unremarkable physical examination exclude severe bacterial infection or complications 2
• The presence of clear (not purulent) nasal discharge argues against bacterial superinfection, as purulent nasal drainage is a cardinal symptom required for ABRS diagnosis 2

Secondary Finding: Orthostatic Presyncope

The single 5-minute episode of "vision going static" triggered by sudden positional change represents presyncope (near-syncope) rather than true vertigo:

• Presyncope is characterized by visual disturbances ("tunnel vision," dimming, or "static"), light-headedness, and near-loss of consciousness without actual syncope 2
• The trigger of sudden positional change in the context of acute febrile illness with disrupted sleep patterns suggests orthostatic hypotension secondary to volume depletion and systemic illness 2
• This is NOT benign paroxysmal positional vertigo (BPPV), which causes brief (<1 minute) episodes of rotational vertigo ("room-spinning"), not visual dimming 3, 4
• The absence of true rotational vertigo, nystagmus, or recurrent episodes makes peripheral or central vestibular pathology unlikely 3, 4

Evidence-Based Management Algorithm

Immediate Symptomatic Treatment (Days 1-3)

Provide the following symptomatic therapies 1:

• Analgesics: Acetaminophen 500-1000 mg every 6 hours or ibuprofen 400-600 mg every 6-8 hours for fever, headache, and general discomfort 1
• Nasal decongestant: Pseudoephedrine 30-60 mg every 4-6 hours (or oxymetazoline nasal spray for ≤3 days) for nasal congestion 1, 5
• Adequate hydration: Emphasize oral fluid intake to prevent orthostatic symptoms 1
• Rest and sleep hygiene: Address disrupted sleep patterns 1

If Symptoms Persist Beyond 3-5 Days

• Do NOT prescribe antibiotics unless the patient develops criteria for ABRS (symptoms persisting ≥10 days, worsening after improvement, or severe onset) 2, 1
• Consider adding throat lozenges if sore throat develops 1
• Avoid cough suppressants (including benzonatate); if cough becomes persistent, consider inhaled ipratropium bromide 1

Red Flags Requiring Urgent Re-evaluation

Instruct the patient to return immediately if any of the following develop 1, 6:

• Symptoms persist beyond 10 days without improvement 2, 1
• Worsening after initial improvement (biphasic pattern) 2, 6
• High fever (≥39°C) with purulent nasal discharge for ≥3 consecutive days 6
• Severe headache, facial swelling, visual changes, or neurological symptoms 2, 3
• Recurrent episodes of visual disturbance or actual syncope 2, 3
• Severe postural instability with falling 3

Diagnostic Testing: NOT Indicated

No imaging or laboratory testing is warranted at this time 2:

• Plain radiographs, CT, and MRI are not necessary for uncomplicated acute viral URI 2
• Radiographic imaging has significant false-positive and false-negative results in acute sinusitis and should be reserved for suspected complications 2
• CT head has a diagnostic yield of <1% for isolated dizziness without trauma or focal neurological deficit 2, 3
• The single presyncope episode with clear orthostatic trigger does not warrant syncope workup in the context of acute febrile illness 2

Expected Clinical Course and Patient Education

Counsel the patient and family on the following 1:

• This is a self-limited viral illness expected to improve within 5-7 days 1
• Fever and constitutional symptoms typically resolve within 24-48 hours 1
• Respiratory symptoms (nasal congestion, rhinorrhea) peak by days 3-6 1
• Nasal discharge may change color (yellow or green) during normal viral resolution—this does NOT indicate bacterial infection or need for antibiotics 2, 1
• The visual episode was likely orthostatic presyncope related to fever and dehydration; maintain adequate hydration and avoid sudden positional changes 2

Critical Pitfalls to Avoid

• Do NOT diagnose ABRS or prescribe antibiotics based on 1-day symptom duration—this leads to unnecessary antibiotic exposure and resistance 2, 1
• Do NOT assume the visual episode represents vertigo or vestibular pathology without true rotational symptoms or recurrence 3, 4
• Do NOT order neuroimaging for a single presyncope episode in the context of acute febrile illness with normal vital signs and examination 2, 3
• Do NOT overlook the importance of hydration counseling to prevent recurrent orthostatic symptoms 1
• Be aware that approximately 40% of viral URIs show CT evidence of sinus mucosal involvement, but this does NOT indicate bacterial infection or need for treatment 2