Learning Objectives:

• Differentiate between viral upper respiratory infection and bacterial sinusitis.
• Be familiar with risk factors for both sinusitis and bronchitis.
• Develop a differential for “cough” illnesses.
• Understand appropriate use of antibiotics for upper respiratory tract infection/lower respiratory tract infection in the ambulatory setting.
• Appropriate workup and testing in a cost-effective manner.
• Be familiar with usual pathogens for common respiratory infections.
• Be familiar with usual clinical presentation for sinusitis, viral upper respiratory tract infection, bronchitis, and pneumonia.

Suggested Readings:

Mainous AG, Hueston WJ. Acute Respiratory Infections (Chapter 17), In: Sloan PD, Slatt LM, Ebell MH, Jacques LB, eds. Essentials of Family Medicine, 4th ed. Philadelphia, PA: Lippincott, Williams and Wilkins, 2002, 259 – 276. Note: This is the required text for the FM Preceptorship.

Case 1

A 43-year-old female presents to your office with a 5 day history of low grade fever of 100.1 F, nasal discharge initially clear, but now turning yellow in color, nasal congestion and a minimally productive cough. She notes that she had a sore throat the first 2 days, but that has now resolved. She denies myalgias, shortness of breath, and ear pain, but does admit to mild headache. On physical exam, the nasal mucosa is swollen and erythematous. There is a small amount of whitish discharge inside the left naris. The tympanic membranes are clear; posterior pharynx is mildly erythematous. Lungs are clear to auscultation.

Question 1: Does this patient need antibiotics?

Question 2: What workup (if any) needs to be done?

Question 3: What can be done to manage her symptoms?

Case 2

A 37-year-old male complains of a 4-week history of cough productive of greenish sputum. Symptoms initially started with nasal congestion and rhinorrhea, but those resolved after the first 7 days. He notes he has become increasingly dyspneic and short of breath. He has had some chills, but has not taken his temperature at home. He admits to smoking 1 ½ pack per day since age 18, although he has not smoked at all in the last 3 days. He notes he had a similar illness about 6 months ago. On examination he is in no respiratory distress. 
Temperature 100.5. Pulse ox 94% on room air. HR 90. Lung examination reveals diffuse rhonchi and wheezes throughout both lung fields.

Question 1: What is the diagnosis?

Question 2: What tests would you order?

Question 3: What treatment would you recommend?

Question 4: What kind of counseling does he need?

Case 3

18-year-old male presents complaining of 2 weeks of severe nasal stuffiness, bilateral facial pain and fatigue. He has tried using OTC Sudafed without benefit. He admits to being fatigued, but denies fevers. His mother notes that he snores while asleep at night. He has a slight cough and some postnasal drip as well. On physical examination, his conjunctivae are bilaterally injected. The nasal mucosa is boggy, pale and edematous. There is purulent discharge in both nares. Maxillary sinuses are tender to palpation bilaterally and poorly transilluminate.

Question 1: What is this patient’s diagnosis? What are typical pathogens?

Question 2: What significant comorbidity does this patient have?

Question 3: What other treatment does he need?

Case 4

55-year-old male comes to your office complaining of severe left-sided chest pain, fever, rigors, and cough productive of rusty colored sputum. He feels a bit short of breath and also complains of malaise. He does not smoke. He is currently on no medications. On physical examination, his temperature is 102, pulse 105, respiratory rate 22, blood pressure 156/96. His lung examination reveals localized rales and rhonchi over the left base.

Question 1: What is your diagnosis?

Question 2: What are the most likely etiologic agents?

Question 3: What will you likely see on this chest x-ray?

Question 4: What treatment would you recommend?

Question 5: Can this patient be managed as an outpatient or does he need hospital admission?