Instructor version of discussion cases: Upper/Lower Respiratory Tract Infections

Note: This information is for preceptors only. Students are asked to not access this information and to respect this restriction as an honor code issue.

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.

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?

No. She has an uncomplicated viral URI. She has a short duration of symptoms and benign physical exam. Nasal discharge normally turns yellow or even green after several days and thus does not indicate bacterial infection. Antibiotic therapy only increases the prevalence of resistant pathogens.

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

None necessary at this point.

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

Fluids, rest, OTC decongestants, cough suppressants or analgesics as needed for symptom relief. Zinc gluconate lozenges and vitamin C have little data supporting their effectiveness. Echinacea may be helpful in prevention and/or in treatment (reducing symptom duration) but randomized, prospective studies are needed.

A 37-year-old male complaining of a 4-week history of cough productive of greenish sputum. Symptoms initially started with nasal congestion and rhino rhea, 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 1/2 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 99.5. Pulse ox 94% on room air. Lung examination reveals diffuse rhonchi and wheezes throughout both lung fields.

Question 1: What is the diagnosis?

Acute exacerbation of chronic bronchitis in a long-term smoker. He has a long duration of symptoms including productive cough and dyspnea and signs such as rhonchi, wheezes, and poor oxygenation.

Question 2: What tests would you order?

Consider a CXR to rule out pneumonia. Sputum cultures are unreliable.

Question 3: What is a common controversy in taking care of this patient?

Antibiotic therapy has been shown to be marginally if at all useful.

Question 4: What kind of counseling does he need?

Smoking cessation.

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 conjunctiva 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?

Maxillary sinusitis is usually caused by Strep Pneumoniae or H. influenza (especially in smokers). 

Question 2: What significant comorbidity does this patient have?

Allergic rhinitis is suggested by his exam findings (conjunctivitis and pale edematous nasal mucosa). 

Question 3: What other treatment does he need?

7 - 14 days antibiotics (penicillin or amoxicillin) may be useful. Antihistamine and/or nasal steroid therapy is indicated for allergic symptoms.

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?

Community acquired pneumonia is suggested by fever, productive cough, and tachypnea. Rales on exam support diagnosis. 

Question 2: What are the most likely etiologic agents?

S. pneumonia (20 - 60%), H. influenza ( 3 - 10%). Atypicals: Legionaella and Mycoplasma (10 - 20%), viruses (2 - 15%). 

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

An infiltrate in the left lung base would confirm the diagnosis. False negatives are rare, but can occur early, or with dehydration or neutropenia. 

Question 4: What treatment would you recommend?

Because of drug-resistant S. pneumonial emergence, penicillin is no longer the drug of choice in most areas. The CDC recommends macrolides, doxycycline, or _-lactamase inhibitors. New fluoroquinolones are effective but should be reserved for use in patients with allergies to above agents, failed therapy, or known resistance. Pneumococcal vaccine is not yet indicated in this age group. 

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

This patient could be managed as an outpatient since he is young, otherwise healthy, and does not smoke.