So, today, we’re going to be discussing
upper respiratory symptoms,
and particularly upper respiratory types of infection.
Now, this is something that,
while a medical student,
you may have seen a lot of in practice.
Or if you came to a practice like mine,
not really that much.
But one thing we can't deny is just how
common upper respiratory symptoms are
and how important it is to differentiate
what is a benign viral upper respiratory
infection from something more sinister,
and then how to treat it appropriately.
And that’s what we’re going to cover today.
So, I’m going to give
you a case to consider.
And we’re going to return to
this case a few times during the discussion
just to provide a nice context
for what I want to discuss with you.
So, I’ve got a 50-year-old man.
He's got a one-week history of cough.
Temperature is normal, 37.2°C.
And the rest of his vital signs are normal.
I’m going to ask you a question just to stop here.
He’s got a one-week history of cough.
That's really all we know.
This might be information that you
know before going in the room,
collected by your medical
assistant or your nurse.
And so, what's the most concerning finding on further
history and physical examination in this case?
Would it be, A, hemoptysis;
B, left ear pain and difficulty hearing;
C, a frontal headache;
or D, a history of smoking?
I’d say it’s A, hemoptysis.
Hemoptysis should not be
part of a typical presentation
for a mild or viral upper respiratory infection.
It can occur.
But I also think about
much more sinister things,
such as certainly pneumonia,
tuberculosis would be a classic here,
or there’s some other –
maybe like a bronchogenic carcinoma even
or some other anatomic abnormality
that’s making them cough up blood.
So, as I said,
upper respiratory infection really common.
People didn't believe me that the average
number of upper respiratory infections
per year among young children,
in particular preschool, is six.
And, yes, these kids – I know from personal
experience – are sick quite a lot
and they make their mom and dad sick too.
Once you reach adolescence and
later in adulthood, that risk goes down.
And older adults actually don't get that
many upper respiratory infections.
But, of course, they are more at risk for
complications of those infections.
So the common cold is certainly the most
common type of upper respiratory infection,
but you can't forget about pharyngitis alone.
Rhinosinusitis can be a complication frequently of
what starts as a basic upper respiratory infection.
Laryngitis, another complication.
And laryngotracheitis is even more rare.
Don't see it a lot.
So, what else do you need to know?
When I'm going through my differential on
patients who come in with, say, cough,
first of all,
I want to know about other
symptoms associated with cough.
Do they have nasal congestion
or do they have rhinorrhea?
Do they have ocular symptoms –
tearing, burning, itching or drainage?
Do they have ear symptoms?
Can they hear?
Are their ears plugged or painful?
So, many times –
and then also with cough,
you think about respiratory symptoms.
Are they short of breath
or have they noticed a wheeze?
What kind of cough is it?
Is it a wet cough or a dry cough?
Doesn’t tell you a lot in terms of differentiating from an
upper respiratory infection versus a lower respiratory infection
unless it's a patient, say, with chronic bronchitis
or chronic obstructive pulmonary disease,
in which case increasing sputum and increasing cough in and of itself can
be an indication for antibiotics among that more rare set of patients.
So, that’s not a healthy adult.
That’s a patient with COPD.
What about sick contacts?
I feel a lot more relieved that,
okay, this is probably a viral upper respiratory infection
when they have a local contact with somebody with a URI.
And what about confounding illnesses?
So, I mentioned COPD.
Asthma is another.
Allergic rhinitis is a third.
And what about medications that
might promote cough?
So, what are causes of chronic cough?
They’re most common.
Postnasal drip, a lot of rhinitis there.
It's things like asthma or GERD,
but it's also –
and I think this is actually the second most common
cause in my practice now, ACE inhibitors.
So, think about medications
that can promote cough too.
ACE inhibitors are broadly used now
for treating hypertension and managing
chronic kidney disease and heart failure as well.
And then, what treatment has been tried.
Always important in any history,
but particularly here patients come
up with their home remedies,
some of which can be
highly effective for them,
not a lot are evidence-based frankly,
but if it works for them,
maybe that’s a sign that it should
continue to work in the future.