What is the most likely diagnosis and recommended management for a patient presenting with sore throat, nasal congestion, cough, and sinus pressure?

Acute Viral Upper Respiratory Tract Infection (Common Cold)

This presentation is most consistent with an acute viral upper respiratory tract infection (common cold), which requires symptomatic management only—antibiotics are not indicated unless specific criteria for bacterial superinfection are met.

Most Likely Diagnosis

The constellation of sore throat, nasal congestion, cough, and sinus pressure of presumed short duration represents a viral URI, which accounts for the vast majority of these presentations and typically resolves within 7-10 days 1. The symptoms described are classic for viral rhinosinusitis, where nasal congestion and cough commonly persist into the second week even as other viral symptoms resolve 1.

Key Diagnostic Considerations

When to suspect bacterial superinfection (acute bacterial rhinosinusitis):

• Persistent symptoms lasting >10 days without any improvement 1, 2
• Severe symptoms including fever ≥39°C (102.2°F) with purulent nasal discharge for ≥3 consecutive days 1
• Worsening symptoms (double sickening): new onset or worsening of fever, headache, or nasal discharge after initial improvement 1

Critical point: Fewer than 2% of viral URIs are complicated by acute bacterial rhinosinusitis 1. Purulent or colored nasal discharge alone does NOT indicate bacterial infection—this commonly occurs after a few days of viral infection due to neutrophil influx and is entirely consistent with uncomplicated viral rhinosinusitis 1, 2.

Recommended Management

Symptomatic Treatment (First-Line)

Analgesics for sore throat and sinus pressure:

• Ibuprofen 400-600 mg every 6-8 hours as needed, OR
• Acetaminophen, OR
• Naproxen 1, 2, 3

For nasal congestion:

• First-generation antihistamine + oral decongestant (e.g., dexbrompheniramine 6 mg + pseudoephedrine 120 mg SR twice daily) is most effective for post-viral upper airway symptoms 2
• High-volume saline nasal irrigation 2-3 times daily—no rebound effect and improves mucociliary clearance 2, 4
• Topical decongestants may be used but limit to 3-5 days maximum to avoid rebound congestion 2

Avoid: Newer-generation antihistamines (loratadine, cetirizine) lack anticholinergic activity and are ineffective for viral URI symptoms 2.

Antibiotic Therapy—ONLY When Indicated

Antibiotics should NOT be prescribed for uncomplicated viral URI 1, 5. They provide minimal symptom benefit (number needed to treat = 6-21 for modest improvement), increase adverse effects, and promote resistance 1.

Prescribe antibiotics ONLY when ALL of the following bacterial criteria are met:

• Symptoms persist >10 days without improvement, AND
• Purulent nasal discharge present, AND
• Facial pain/pressure present 1, 2, 4

First-line antibiotic when indicated:

• Amoxicillin 500 mg three times daily for 10-14 days, OR
• Amoxicillin-clavulanate (covers β-lactamase producers) 1, 2, 4, 6

Alternative if penicillin allergy:

• Cefuroxime axetil or other oral cephalosporin 1, 6

When to Reassess or Refer

Return immediately if:

• Symptoms persist >10 days without improvement 2
• Symptoms worsen after initial improvement (double sickening) 2
• High fever >39°C with severe unilateral facial pain develops 2
• Red flags: Periorbital edema/erythema, vision changes, severe headache with neck stiffness, mental status changes—these suggest orbital or intracranial complications requiring urgent evaluation 2, 4

Consider further workup if no improvement after 2 weeks of appropriate therapy:

• Chest radiograph to exclude pneumonia 2
• Spirometry to rule out underlying asthma or COPD 2
• ENT referral for nasal endoscopy if structural abnormalities suspected 2

Common Pitfalls to Avoid

• Do not prescribe antibiotics based on symptom duration <10 days—87% of adults with acute URI symptoms show sinus inflammation on CT, but 79% resolve spontaneously within 2 weeks without antibiotics 1
• Do not assume green/yellow mucus = bacterial infection—color reflects neutrophils and desquamated epithelium from normal viral inflammation 1, 2, 4
• Do not use imaging routinely—radiographic abnormalities occur in up to 40% of asymptomatic adults and have poor specificity (61%) for bacterial infection 1, 4
• Do not overlook underlying asthma—persistent cough despite appropriate URI treatment warrants bronchodilator trial and spirometry 2