Upper Respiratory Tract Infection on the CCFP exam

Approach

• Know the danger signs: drooling, a muffled voice, sitting forward to breathe, noisy breathing in, and a child who looks very ill.
• Suspect a swollen epiglottis (the flap over the windpipe) with sudden high fever, drooling and a toxic look.
• Suspect pus behind the throat (retropharyngeal abscess) in a young child with fever, neck pain and a stiff neck that will not tip back.
• A simple sore throat swallows, talks normally and has cold symptoms. Swab for strep only if the modified Centor score (a sore-throat score) is 2 or more and there are no cold symptoms.

Approach

• Wait for time. Bacterial sinusitis rarely shows before 7 days. Think of it when symptoms last 7 to 10 days without improving, or get better then worse.
• Count PODS: Pain or pressure in the face, nasal Obstruction, Discoloured discharge, Smell loss. You need 2, and one must be O or D.
• Mild to moderate: start a nasal corticosteroid spray. Add an antibiotic if there is no better after 72 hours.
• Past 7 to 10 days, severe symptoms earn an antibiotic without the steroid trial. A fever over 38.6 °C can warrant one right away.
• When you choose an antibiotic, amoxicillin is the first choice.
• Give the antibiotic for 5 to 10 days.
• No CT scan and no sinus X-ray for uncomplicated sinusitis. The diagnosis is made at the bedside.
• Image only when you suspect a complication. Look for severe headache, confusion, face swelling, a bulging eye, or a cranial nerve palsy (weakness of an eye or face muscle).

Approach

• No antibiotic for a cold or a flu-like illness unless a bacterial infection clearly follows.
• No antibiotic for acute bronchitis. Sputum colour does not tell viral from bacterial.
• Warn that the cough lasts up to 3 weeks in half of patients, and over a month in a quarter. A cough past 14 days is not bacterial by that alone.
• No cough and cold medicines under age 6. They can cause serious harm, including accidental overdose.
• Where you are unsure, offer a recheck or a delayed prescription. About a third of patients fill a delayed prescription.
• Explain the plan and how to ease symptoms. Satisfaction follows the talk, not the prescription.

Approach

• Middle ear: a bulging, red or yellow eardrum that moves poorly. The canal looks normal.
• Outer ear: pain when you press the tragus (the flap in front of the canal) or pull the ear, and a swollen canal with debris. Treat uncomplicated cases with antibiotic drops, not pills.
• Mastoid: red, tender swelling behind the ear, with the ear pushed forward.
• Fluid behind an eardrum that does not bulge, with no fever or pain, is effusion. Most clears within 3 months.
• Give a middle ear antibiotic for pus from a hole in the eardrum. Or for a bulging eardrum plus one of: fever of 39 °C or more, moderate to severe illness, or over 48 hours of symptoms.
• Infants 6 months or younger often need an antibiotic right away. So may a child with a cleft palate, Down syndrome, an immune disorder or a cochlear implant.
• Start pain relief with acetaminophen or ibuprofen. Antibiotics do not ease pain in the first 24 hours.

Approach

• High risk includes human immunodeficiency virus (HIV), cancer treatment, other immune suppression and COPD. See the patient in person; check vital signs and the chest.
• Sinusitis with face swelling, a bulging eye, a cranial nerve palsy, severe headache or confusion is a complication. Consider a CT scan of the sinuses.
• In an immunocompromised child, sinus imaging is reasonable even without those signs.
• COPD flare after a cold: antibiotic only with more purulent (pus-like) sputum plus more sputum or more breathlessness. Oral steroids help; 5 days works as well as longer.
• Pneumonia needs objective evidence; crackles alone are not enough. Normal vital signs and chest exam make it unlikely.
• Book a recheck. Tell the patient which signs mean come back sooner.

Approach

• Think of mono in a teen or young adult with sore throat, fever, marked tiredness and large nodes.
• Feel the back of the neck: nodes there point to mono more than strep.
• Feel for a big spleen and liver.
• A positive strep test does not exclude mono. Many children carry strep with no illness.
• Swab for strep only with a modified Centor score of 2 or more and no cold symptoms such as runny nose, mouth ulcers or hoarseness.
• With a big spleen, no contact sport until it settles.

Approach

• Offer flu vaccine every year. October or November is the best time.
• Ask about pneumococcal vaccine in younger adults with heart, lung or liver disease, diabetes, alcohol problems, or who smoke.
• Do not test every flu-like illness. Test early in the season or in an outbreak, or when the result would change care.
• No antibiotics for a flu-like illness unless a bacterial infection clearly follows.
• See high-risk patients with flu early.