Upper respiratory disease is a term that encompasses acute infections ranging from the benign common cold to life-threatening conditions (e.g., epiglottitis). Cases of upper respiratory disease are easy to recognize because the patients will complain about the following symptoms (Centers for Disease Control and Prevention [CDC], 2016):
Runny nose (always)
Sore throat (always)
Coughing (common, usually in cases of viral etiology)
Sneezing (common, usually in cases of viral etiology)
Other symptoms depend on the patient’s age, medical history, and the pathogen causing the infection, so it is important to conduct a thorough assessment which consists of the following steps:
Interview the patient.
Perform a physical examination.
Analyze the patient’s history.
Interviewing the Patient
Before conducting the physical exam of the upper respiratory system, it is important to interview the patient and find out more about the onset and the duration of the symptoms. Ask the patient the following questions:
“What were the first symptoms you noticed?”
Ask follow-up questions to make sure the patient remembers all relevant symptoms that appeared at the onset of the illness (e.g., “Did you experience a fever? Was it mild or severe?”). Use the following symptoms as guidelines to ask follow-up questions and start narrowing the possible diagnoses (Mossad, 2013):
Sneezing, nasal congestion, and a sore throat without other symptoms: suspect the common cold.
Fever and conjunctivitis: suspect adenoviral pharyngitis.
Exposure to a known case of streptococcal pharyngitis, sore throat, fever, and absence of coughing: suspect group A streptococcal pharyngitis.
Headache, maxillary toothache, purulent nasal discharge, and unilateral facial pain: suspect bacterial rhinosinusitis.
“When did you first experience the symptoms? Are the symptoms getting better or worse?”
Depending on the duration of the symptoms, the following conclusions can be made:
Between 3-14 days, symptoms consistent or improving: Normal duration for upper respiratory infections. Proceed with physical examination.
Worsening symptoms after 5-7 days: High probability of a bacterial infection and may require testing for specific pathogens.
Longer than 10 days: High probability of a bacterial infection and may require testing for specific pathogens.
Longer than 14 days: Skip the physical examination for upper respiratory infections and proceed testing the patient for alternative conditions, such as mononucleosis, pneumonia, tuberculosis, or allergies.
“When was the last time you travelled abroad?” If the patient returned from abroad recently (i.e., within the past two weeks), ask the follow-up question: “Which country or countries did you visit?”
As a general rule, respiratory infections are similar for both travelers and non-travelers (LaRocque & Ryan, 2015). However, if the patient has been travelling recently and the clinical presentation includes a fever, the following conditions are the most common (Fairley, 2015):
Seasonal influenza
Bacterial pneumonia
Malaria
The highest risk of upper respiratory infections occurs in the following regions (Leder et al., 2003):
Central Asia
Indian subcontinent
Southeast Asia
The aforementioned locations are common sources of upper respiratory infection outbreaks, so it is important to consider the following for travelers who visited those regions (Fairley, 2015):
The patient visited countries with known emerging respiratory infections.
There is no clear alternative diagnosis other than the emerging infection.
If a case meets these two criteria, notify the local public health authorities and the CDC.
Performing the Physical Examination
The physical examination for upper respiratory disease focuses on the nose, throat, lungs, and neck. The following steps will be necessary for a thorough physical examination:
Nasal examination: Use the Thudichum speculum to open the nose and observe for signs of inflammation, septum position, polyp presence, structural anomalies, and discharge.
Throat examination: Press the tongue down with a depressor. Inspect the tonsils and pharynx for signs of inflammation, including erythema, swelling, and exudates.
Neck examination: Palpate the neck to determine if the lymph nodes are swollen.
Lung examination: Listen for wheezing or crackling sounds using a stethoscope. Inspiratory stridor may be present in upper respiratory infections.
Body temperature: Measure the patient’s body temperature, even if the patient does not have a fever during the examination.
Compare the results of the physical examination with the symptoms listed in Table 1 to determine the most probable diagnosis.
Order additional tests if the following cases are suspected:
Group A streptococcal pharyngitis: Order a rapid-detection assay of culture swabs.
Epiglottitis: Order radiology or computed tomography for a visual evaluation of the epiglottis.
Acute bacterial rhinosinusitis with possible structural anomalies: radiology or computed tomography for a visual evaluation of the sinuses.
Progressive upper respiratory infections: If the symptoms continue for more than 14 days, test for alternative diagnoses such as pneumonia, mononucleosis, allergies, or tuberculosis.
Most Common Symptoms by Upper Respiratory Infection.
Patient History Considerations
Medical, family, and social histories are often necessary considerations in upper respiratory infections because they can explain unusual progressions of an infection or inform treatment selection.
Medical history: Check the patient’s medical history for the following:
Allergies: May explain prolonged symptoms and affect antibiotic treatment safety.
Asthma or COPD: Consider the possibility of acute exacerbations and overlapping symptoms during therapy.
Coronary artery disease, hypertension, or stroke history: Avoid decongestants in therapy.
Family history: Research the family history of the patient for hereditary conditions that increase probability of upper respiratory infections and prolonged infection symptoms:
Allergies
Asthma
COPD
Social history: Ask the patient about:
Interactions with friends, family members, or co-workers who have upper respiratory infections.
Interactions with people who have a group A streptococcal pharyngitis diagnosis. This is required to diagnose streptococcal pharyngitis infections.
References
Centers for Disease Control and Prevention. (2016). Common colds: Protect yourselves and others. Retrieved from http://www.niaid.nih.gov/topics/commoncold/Pages/default.aspx
Fairley, J. K. (2015). General approach the returned traveler. Retrieved from http://wwwnc.cdc.gov/travel/yellowbook/2016/post-travel-evaluation/general-approach-to-the-returned-traveler
LaRocque, R. C., & Ryan, E. T. (2015). Respiratory infections. Retrieved from http://wwwnc.cdc.gov/travel/yellowbook/2016/the-pre-travel-consultation/respiratory-infections
Leder, K., Sundararajan, V., Weld, L., Pandey, P., Brown, G., Torresi, J., & GeoSentinel Surveillance Group. (2003). Respiratory tract infections in travelers: A review of the GeoSentinel surveillance network. Clinical Infectious Diseases, 36(4), 399-406.
Mossad, S. B. (2013). Upper respiratory tract infections. Retrieved from http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/infectious-disease/upper-respiratory-tract-infection/
