So, let’s return to our coughing man.
So, we've added to his history now.
He's got non-productive cough.
It’s slightly worse at night.
He has sore throat and malaise.
he's had no shortness of breath,
no facial pressure.
He took care of a grandchild two weeks ago
and she had an upper respiratory infection.
He has a history of gastroesophageal reflux
disease and seasonal allergies.
So, let's take a second just to breakdown
that history before going to the question.
So, no fever, no shortness of breath,
no facial pressure.
So, makes it sound like an
asthma or COPD exacerbation.
It is less likely.
So is sinusitis.
He's got the target there,
the vector case of his grandchild probably gave
him the URI that history matches up really well.
He also has a couple of reasons
for chronic cough in there as well,
with the GERD and the seasonal allergies.
So, that’s something to consider.
So, putting that altogether, though,
what do you think is the most likely
source of this patient's symptoms?
Is it, A typical bacteria such as a pneumococcus;
B, a typical bacteria such as mycoplasma;
C, GERD and the allergic rhinitis,
just exacerbation of those together;
or D, viral infection?
And the answer is D.
This came on more abruptly.
It’s a one-week history.
The cough, worse at night,
probably consistent with a
little post-nasal drainage.
He has sore throat and malaise,
which you wouldn’t necessarily
get with a GERD and allergic rhinitis,
and he has the upper respiratory infection contact.
So, it sounds very much like a typical cold.
So, of course, you’re going to do physical on this patient.
Things that I look for,
his nares might tell you a little bit of a story,
maybe more erythema in a patient with an infection,
maybe more blue or boggy mucosa
in somebody with rhinitis alone,
allergic rhinitis in particular.
In the oropharynx,
watching out for pharyngitis.
So that differences –
are there exudates or no exudates.
Erythema is going to be very common because of
all the drainage that patients have down their throat.
Lymphadenopathy would also suggest an acute infection
versus just something related to his GERD and rhinitis.
And of course, listening to the lungs.
If there's any lung finding,
it's almost certainly going to
make me consider a chest x-ray,
particularly if it’s a new finding
because I'm worried about pneumonia.
The most common finding,
classic being rhonchi,
but you can hear crackles
and sometimes wheezes too.
Whereas in the typical viral
upper respiratory infection,
lungs are clear.
I think one of the most difficult things is trying
to differentiate clinically influenza versus common cold.
It's important clinically because you want to
institute treatment for influenza as fast as possible,
at least within 72 hours of symptom onset
for the antiviral drugs to be effective.
One simple way to break it down
is more systematic symptoms.
Think of influenza.
More localized symptoms to the head and to the throat,
think of a common cold.
So, influenza, it’s just going to –
it’s going to knock you out.
You’re going to get more myalgia,
more of those constitutional symptoms across your entire body.
And you also get a more severe cough.
Whereas a common cold,
you’ll get more sore throat,
more nasal congestion.
So, localized symptoms to the upper respiratory tract alone.
It’s a help, but it’s still –
physicians are pretty bad at predicting clinically
what's influenza versus a common cold,
particularly at the incipient stages of illness.
So, back to the coughing man.
His exam reveals some erythema of his turbinates.
He’s got posterior –
he’s got erythema in his posterior oropharynx as well,
but no exudates,
and he has some posterior cervical lymphadenopathy
and clear lungs as well.
So, given that,
let’s think about treatment
because I think diagnosis of upper
respiratory infection is cinched in my mind now,
let’s think about how we
can make him feel better.
So, is the best idea strict bed rest for a few days?
Can analgesics help his malaise?
Or C, Amoxicillin or macrolide will reduce
the duration of his symptoms?
Or D, decongestants have the best record of
efficacy in improving your eye symptoms?
The answer is B.
So, let's talk about the care for the common cold.
Maybe dispel some myths along the way.
First of all, antipyretics/analgesics
should be a mainstay of therapy
because they are very safe
and generally very effective,
particularly when taken for the short term.
for particularly upper respiratory symptoms
in terms of the cough and congestion,
there is no medicine unfortunately
that's really been found to be consistently effective.
And yet, many parents will employ
antihistamines and employ cough suppressants.
That often can lead to grogginess
and rarely can lead to more symptoms among children.
really try to avoid those if possible.
But I can tell you,
again from personal experience,
that nasal suction really works
and there's products which you can create,
using your mouth as suction,
negative pressure and that works a heck
of a lot better than a simple bulb
and we’re talking about
particularly here for infants.
As they get a little older,
they can blow their own nose,
but it's really terrible to see a four-month
old struggling with a very stuffy nose.
And so, there are some commercial products out there,
fairly cheap, that really do work well to suck out that snot.
That said, whoever invents a cure –
and you’re all young physicians.
If you invent a cure for pediatric snot,
you should absolutely win a Nobel Prize.
And call me because I’ll personally send you money
because it's really necessary and important in this planet.
For adults, guaifenesin has some
mixed record of evidence.
Some studies say it works;
some studies say it doesn’t.
Mucolytics generally may improve symptoms.
They’re fairly side effect free.
So, certainly consider them,
particularly for patients
who have a lot of congestion.
Bed rest is good for
keeping the infection localized,
but it isn’t really going to make a
difference in the duration of illness.
It may feel better,
but patients who continue to go to work
get better at about the same rate regardless.
And then, certainly,
I want to practice good stewardship,
and that means avoiding the broad use of antibiotics
for most cases of upper respiratory infection.
Let’s talk about antibiotic use.
So, when antibiotics may be necessary?
So, one of the cases is rhinosinusitis.
Our case did not have it.
He didn’t sinus pressure.
He didn’t have a long duration of symptoms.
Duration doesn't correlate
perfectly with the risk of sinusitis,
but generally it's accepted that
symptoms that are persisting
for more than 10 days or getting worse,
that means it might be time –
and particularly when they’re
associated with facial pressure
and continued congestion,
that's when rhinosinusitis may be in order.
Don't use the broad-spectrum agents.
You can stick to specific and simple
antibiotics, such as amoxicillin.
Works just as well.
And it’s going to be –
promote less antimicrobial resistance.
The treatment period is considerable,
and that's something that
patients need to commit to.
They might feel better sooner,
but definitely have them take the antibiotics
for 10 days once they commit to them.
For the other considerations,
the patient who doesn't usually have cough,
doesn't have a lot of congestion,
but does have pharyngitis with lymphadenopathy
and also has some exudates on the throat,
that patient probably has a
group A streptococcal infection.
Penicillin still preferred.
It’s a 10-day course.
It doesn't really improve the duration of symptoms that much.
Maybe by a day or two.
But it does prevent rheumatic fever,
and that's why penicillin is recommended
n cases of group A streptococcal infection.
It does not, however, improve the risk of
These are rare complications of
a streptococcal infection,
which is a fairly common one,
but nonetheless they’re important complications
because they can have serious consequences.
And just remember,
as always, a great way to diagnose Epstein-Barr
virus that you weren't thinking about
is giving the patient amoxicillin for
it and they break out in a rash.
That's very pathognomonic
for Epstein-Barr infection.
And so, hopefully,
you have learned some tricks in
identifying viral upper respiratory infections
and differentiating the type of infection a little bit,
particularly the ones that might need antibiotics.
And we covered some treatments,
limited as they may be,
for improving symptoms in the common cold.
I think the key is really be
upfront with your patients.
Practice shared decision-making.
And do no harm in recommending a whole wide array
of over-the-counter products or other treatments
for the common cold because they might –
they’re probably not going to work
and they might produce some serious side effects.