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Upper Respiratory Tract Infection (URTI)
Overview
Clinical Features
Management
Problem Representation
  • A 30-year-old adult presents with a 4-day history of nasal congestion, runny nose, sore throat, and mild cough. The patient also reports low-grade fever, headache, and generalised malaise. Physical examination reveals nasal mucosal swelling and erythema in the pharynx.
Epidemiology
  • Age: Affects individuals of all ages, but more common in children and adults under 50.
  • Seasonality: More frequent in autumn and winter months.
  • Prevalence: One of the most common reasons for primary care visits, highly prevalent.
Temporal Pattern
  • Onset: Gradual onset over 1-2 days.
  • Duration: Symptoms typically last 7-14 days.
  • Course: Self-limiting, with gradual resolution of symptoms; complications are rare but can include secondary bacterial infections.
Mechanism
  • Pathophysiology: Inflammation of the upper respiratory tract mucosa, most commonly due to viral infection (e.g., rhinovirus, coronavirus, adenovirus).
  • Transmission: Respiratory droplets or contact with contaminated surfaces.
Predisposing Conditions
  • Environmental: Close contact with infected individuals (e.g., in households, schools, or workplaces).
  • Personal: Smoking, allergic rhinitis, and exposure to air pollution or dry air.
Key Features (Clinical Presentation)
  • Major Symptoms:
    • Nasal congestion
    • Runny nose (rhinorrhoea)
    • Sore throat
    • Cough (usually dry)
    • Low-grade fever (if present, typically <38°C)
  • Physical Examination:
    • Nasal Mucosa: Swollen, erythematous, and possibly with clear to purulent discharge.
    • Pharynx: Mild erythema, no significant exudate.
    • Sinuses: May be tender to palpation if sinusitis is suspected.
  • Associated Symptoms:
    • Headache
    • Malaise and fatigue
    • Ear discomfort or fullness
    • Post-nasal drip leading to throat clearing
Differential Diagnosis
  • Allergic Rhinitis: Clear nasal discharge, sneezing, itchy eyes, typically seasonal or related to allergen exposure.
  • Sinusitis: Persistent nasal congestion, facial pain/pressure, purulent nasal discharge.
  • Influenza: Sudden onset of high fever, myalgia, and severe fatigue.
  • Streptococcal Pharyngitis: Severe sore throat, absence of cough, higher fever.
Investigations
  • Usually Clinical Diagnosis: Based on history and physical examination.
  • Viral Testing: Rarely indicated unless specific viral identification is necessary (e.g., during outbreaks).
  • Sinus Imaging: Consider if sinusitis is suspected and symptoms persist or worsen after initial treatment.
Management
  • Supportive Care:
    • Analgesics and antipyretics (e.g., paracetamol, ibuprofen)
    • Decongestants (e.g., pseudoephedrine, oxymetazoline)
    • Hydration and rest
    • Saline nasal sprays or steam inhalation for nasal congestion
  • Antibiotics:
    • Not routinely indicated: As URTIs are primarily viral. Consider only if secondary bacterial infection is strongly suspected.
  • Consider Referral:
    • If symptoms persist beyond 10-14 days or if complications such as sinusitis or otitis media develop.
    • Recurrent or severe URTIs requiring further investigation.
Complications
  • Acute: Sinusitis, otitis media, secondary bacterial infections.
  • Chronic: Recurrent URTIs, chronic rhinosinusitis.
Prognosis
  • Typical URTI: Self-limiting, with full recovery in 1-2 weeks.
Prevention
  • Good hand hygiene and respiratory etiquette.
  • Avoid close contact with infected individuals.
  • Annual influenza vaccination may reduce the risk of some viral URTIs.
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Pharyngitis
Overview
Clinical Features
Management
Problem Representation
  • A 25-year-old adult presents with a 2-day history of sore throat, painful swallowing, and mild fever. The patient denies cough or runny nose. Physical examination reveals erythema of the pharynx with swollen tonsils, but no exudate.
Epidemiology
  • Age: Common in both children and adults, particularly those aged 5-15 years.
  • Seasonality: More frequent in late autumn, winter, and early spring.
  • Prevalence: Very common, often related to viral upper respiratory infections.
Temporal Pattern
  • Onset: Acute onset, typically developing over 1-2 days.
  • Duration: Symptoms usually last 3-7 days, depending on the aetiology.
  • Course: Symptoms may resolve spontaneously, especially if viral. Bacterial cases may persist without treatment.
Mechanism
  • Pathophysiology: Inflammation of the pharynx, often due to viral (e.g., rhinovirus, adenovirus) or bacterial (e.g., Group A Streptococcus - GAS) infection.
  • Transmission: Spread via respiratory droplets or direct contact with contaminated surfaces.
Predisposing Conditions
  • Environmental: Close contact with infected individuals (e.g., schools, households).
  • Personal: Smoking, allergic rhinitis, recent exposure to respiratory infections.
Key Features (Clinical Presentation)
  • Major Symptoms:
    • Sore throat (pharyngitis)
    • Painful swallowing (odynophagia)
    • Fever (may be low-grade or higher in bacterial cases)
    • Headache
    • Malaise
  • Physical Examination:
    • Pharynx: Erythematous, may have tonsillar swelling. Exudate is typically absent in viral cases but may be present in bacterial cases.
    • Cervical lymphadenopathy: Anterior cervical lymph nodes may be tender and swollen, particularly in streptococcal pharyngitis.
    • Absence of Cough: Suggestive of streptococcal pharyngitis rather than viral.
  • Associated Symptoms:
    • Hoarseness (more common in viral cases)
    • Ear pain (referred)
    • Fatigue
Differential Diagnosis
  • Viral Pharyngitis: Often accompanied by cold symptoms like cough and rhinorrhoea.
  • Streptococcal Pharyngitis: More likely to present with fever, anterior cervical lymphadenopathy, and pharyngeal exudate.
  • Infectious Mononucleosis: Severe fatigue, prolonged illness, generalized lymphadenopathy, hepatosplenomegaly.
  • Peritonsillar Abscess: Severe unilateral throat pain, trismus, deviation of the uvula.
Investigations
  • Rapid Antigen Detection Test (RADT): For Group A Streptococcus if bacterial pharyngitis is suspected.
  • Throat Swab Culture: If RADT is negative but clinical suspicion remains high.
  • Monospot Test: If infectious mononucleosis is suspected.
Management
  • Supportive Care:
    • Analgesics and antipyretics (e.g., paracetamol, ibuprofen)
    • Gargling with saltwater or using throat lozenges
    • Adequate hydration
    • Rest
  • Antibiotics:
    • Indication: Only if bacterial aetiology confirmed or highly suspected (e.g., positive RADT for GAS).
    • First-Line: Phenoxymethylpenicillin (Penicillin V) for 10 days. For penicillin-allergic patients, consider erythromycin or clarithromycin.
  • Consider Referral:
    • If symptoms persist or worsen despite treatment.
    • If complications such as peritonsillar abscess develop.
Complications
  • Acute: Peritonsillar abscess, otitis media, sinusitis.
  • Chronic: Recurrent pharyngitis, chronic sore throat.
  • Post-Streptococcal Sequelae: Rheumatic fever, post-streptococcal glomerulonephritis.
Prognosis
  • Viral Pharyngitis: Self-limiting, typically resolves within a week.
  • Bacterial Pharyngitis: Rapid improvement with appropriate antibiotic therapy, but may recur.
Prevention
  • Good hand hygiene.
  • Avoiding close contact with infected individuals.
  • Avoid smoking and exposure to secondhand smoke.
Tonsillitis
Overview
Clinical Features
Management
Problem Representation
  • A 6-year-old child presents with a 3-day history of sore throat, difficulty swallowing, fever, and enlarged, tender cervical lymph nodes. The patient also reports headache and malaise. Physical examination reveals erythematous and swollen tonsils with exudate.
Epidemiology
  • Age: Common in children and young adults (typically ages 5-15).
  • Seasonality: More frequent in late autumn, winter, and early spring.
  • Prevalence: Very common, especially in school-aged children.
Temporal Pattern
  • Onset: Acute onset, usually within a few hours to a couple of days.
  • Duration: Symptoms typically last 7-10 days with appropriate treatment.
  • Course: If untreated, symptoms may worsen, leading to complications such as peritonsillar abscess.
Mechanism
  • Pathophysiology: Inflammation of the tonsils caused by infection. Most commonly viral (e.g., adenovirus, rhinovirus) or bacterial (e.g., Group A Streptococcus - GAS).
  • Transmission: Respiratory droplets or direct contact with contaminated surfaces.
Predisposing Conditions
  • Environmental: Close contact with infected individuals (e.g., school, daycare).
  • Personal: History of recurrent tonsillitis, recent viral upper respiratory tract infection.
Key Features (Clinical Presentation)
  • Major Symptoms:
    • Sore throat (pharyngitis)
    • Difficulty swallowing (odynophagia)
    • Fever (often >38°C)
    • Headache
    • Malaise and fatigue
  • Physical Examination:
    • Tonsils: Erythematous, swollen, and may have white or yellow exudate.
    • Pharynx: Red and inflamed.
    • Cervical lymphadenopathy: Enlarged, tender anterior cervical nodes.
    • Halitosis: Common due to bacterial infection.
  • Associated Symptoms:
    • Ear pain (referred)
    • Hoarseness
    • Abdominal pain and nausea (particularly in children)
Differential Diagnosis
  • Viral Pharyngitis: Less severe throat pain, more likely to have associated cold symptoms (cough, rhinorrhoea).
  • Infectious Mononucleosis: Severe fatigue, prolonged illness, hepatosplenomegaly.
  • Peritonsillar Abscess: Severe unilateral throat pain, deviation of the uvula, “hot potato” voice.
  • Epiglottitis: Rapid onset, high fever, drooling, and severe distress.
Investigations
  • Rapid Antigen Detection Test (RADT): For Group A Streptococcus.
  • Throat Swab Culture: If RADT is negative but clinical suspicion remains high.
  • Full Blood Count (FBC): May show elevated white blood cells if bacterial.
  • Monospot Test: If infectious mononucleosis is suspected.
Management
  • Supportive Care:
    • Analgesics (e.g., paracetamol, ibuprofen)
    • Adequate hydration
    • Rest
  • Antibiotics:
    • Indication: Only if bacterial aetiology confirmed or highly suspected (e.g., positive RADT for GAS).
    • First-Line: Phenoxymethylpenicillin (Penicillin V) for 10 days. For those allergic to penicillin, consider erythromycin or clarithromycin.
  • Consider Referral:
    • If recurrent tonsillitis (≥7 episodes in one year, ≥5 episodes per year for 2 years, or ≥3 episodes per year for 3 years).
    • If complications develop (e.g., peritonsillar abscess).
Complications
  • Acute: Peritonsillar abscess (quinsy), parapharyngeal abscess, otitis media.
  • Chronic: Recurrent tonsillitis, chronic tonsillitis.
  • Post-Streptococcal Sequelae: Rheumatic fever, post-streptococcal glomerulonephritis.
Prognosis
  • Viral Tonsillitis: Self-limiting, typically resolves within a week.
  • Bacterial Tonsillitis: Rapid improvement with appropriate antibiotic therapy, but may recur.
Prevention
  • Good hand hygiene.
  • Avoid close contact with infected individuals.
  • Consider tonsillectomy in cases of recurrent or chronic tonsillitis.
Influenza
Overview
Clinical Features
Management
Problem Representation
  • A 45-year-old adult presents with a sudden onset of high fever, severe muscle aches, headache, sore throat, and a dry cough. The patient also reports extreme fatigue and chills. Physical examination reveals a febrile patient with flushed skin and mild pharyngeal erythema.
Epidemiology
  • Age: Affects all age groups, with higher risk of severe disease in very young children, elderly individuals, and those with comorbidities.
  • Seasonality: Most common in winter months, with annual outbreaks.
  • Prevalence: Common, with seasonal epidemics and occasional pandemics.
Temporal Pattern
  • Onset: Abrupt onset, typically within a few hours.
  • Duration: Symptoms usually last 5-7 days, but fatigue and cough can persist for weeks.
  • Course: Rapid worsening of symptoms within 24-48 hours, followed by gradual recovery; complications can occur, particularly in high-risk groups.
Mechanism
  • Pathophysiology: Viral infection of the respiratory tract caused by influenza viruses (types A, B, and C). Type A is most common and associated with epidemics and pandemics.
  • Transmission: Spread via respiratory droplets, direct contact with infected individuals, or contact with contaminated surfaces.
Predisposing Conditions
  • Environmental: Crowded living conditions, close contact with infected individuals (e.g., in households, schools, healthcare settings).
  • Personal: Age extremes, chronic medical conditions (e.g., COPD, diabetes, heart disease), pregnancy, and immunosuppression.
Key Features (Clinical Presentation)
  • Major Symptoms:
    • Sudden high fever (≥38°C)
    • Severe myalgia (muscle aches)
    • Headache
    • Dry cough
    • Sore throat
    • Severe fatigue and malaise
  • Physical Examination:
    • General Appearance: Febrile, flushed, may appear uncomfortable or in distress.
    • Pharynx: Mild erythema, no exudate.
    • Lungs: Often clear to auscultation, but may have rhonchi or wheezing in cases of secondary bronchitis.
  • Associated Symptoms:
    • Chills and sweats
    • Nasal congestion and rhinorrhoea (less common)
    • Anorexia and nausea
Differential Diagnosis
  • Common Cold: Gradual onset, milder symptoms, nasal congestion and rhinorrhoea are more prominent.
  • COVID-19: Similar presentation, but may include loss of taste/smell, more likely to cause severe respiratory symptoms.
  • Streptococcal Pharyngitis: Prominent sore throat, absence of cough, higher fever.
  • Pneumonia: High fever with productive cough, pleuritic chest pain, and possible shortness of breath.
Investigations
  • Rapid Influenza Diagnostic Test (RIDT): For rapid diagnosis, though sensitivity varies.
  • Reverse Transcription Polymerase Chain Reaction (RT-PCR): Gold standard for influenza detection.
  • Chest X-ray: If secondary pneumonia is suspected.
Management
  • Supportive Care:
    • Analgesics and antipyretics (e.g., paracetamol, ibuprofen) for fever and muscle aches.
    • Hydration and rest.
    • Antitussives (e.g., dextromethorphan) for severe cough.
  • Antiviral Treatment:
    • Indication: Recommended for high-risk individuals or if started within 48 hours of symptom onset.
    • First-Line: Oseltamivir (Tamiflu) for 5 days; other options include zanamivir or baloxavir.
  • Consider Referral:
    • If symptoms worsen or do not improve after 48-72 hours of treatment, especially in high-risk groups.
    • If complications such as pneumonia develop.
Complications
  • Acute: Viral or bacterial pneumonia, bronchitis, otitis media.
  • Chronic: Exacerbation of chronic conditions such as asthma or COPD.
  • Severe: Acute respiratory distress syndrome (ARDS), myocarditis, encephalitis.
Prognosis
  • Uncomplicated Influenza: Generally self-limiting with full recovery in 1-2 weeks, though fatigue can persist longer.
  • Severe Cases: Higher risk of complications and mortality in high-risk groups.
Prevention
  • Annual influenza vaccination, particularly for high-risk groups.
  • Good hand hygiene and respiratory etiquette.
  • Avoiding close contact with infected individuals during outbreaks.
Herpes Stomatitis
Overview
Clinical Features
Management
Problem Representation
  • A 3-year-old child presents with a 2-day history of painful mouth sores, fever, and difficulty eating. The parent reports that the child is irritable and refuses food. Physical examination reveals multiple vesicular lesions on the lips, tongue, and gingiva, with surrounding erythema.
Epidemiology
  • Age: Most common in children under 5 years old.
  • Seasonality: No specific seasonal predilection.
  • Prevalence: Primary herpetic stomatitis is relatively common, especially in young children who have not yet been exposed to the virus.
Temporal Pattern
  • Onset: Acute onset, with symptoms developing over 1-2 days.
  • Duration: Symptoms typically last 7-14 days, with gradual resolution.
  • Course: Symptoms start with fever and malaise, followed by the appearance of painful oral lesions. Lesions can rupture and ulcerate, causing significant discomfort.
Mechanism
  • Pathophysiology: Caused by primary infection with herpes simplex virus type 1 (HSV-1). The virus infects epithelial cells, leading to the formation of vesicles that subsequently ulcerate.
  • Transmission: Spread via direct contact with infected saliva, vesicular fluid, or contaminated objects.
Predisposing Conditions
  • Environmental: Close contact with an infected individual, such as a family member or caregiver.
  • Personal: Young age, exposure to individuals with active HSV-1 infection.
Key Features (Clinical Presentation)
  • Major Symptoms:
    • Painful oral lesions (vesicles and ulcers)
    • Fever (often high, >38°C)
    • Poor oral intake due to pain
    • Irritability and malaise
    • Gingivitis (swollen, red, and bleeding gums)
  • Physical Examination:
    • Oral Mucosa: Vesicular lesions on the lips, tongue, gingiva, and hard palate. Lesions may rupture and form ulcers.
    • Cervical Lymphadenopathy: Enlarged and tender lymph nodes in the neck.
    • Dehydration Signs: May be present if oral intake is severely reduced.
  • Associated Symptoms:
    • Halitosis
    • Drooling due to mouth pain
    • Anorexia
Differential Diagnosis
  • Hand, Foot, and Mouth Disease: Caused by coxsackievirus, presents with oral lesions and vesicles on hands and feet.
  • Aphthous Stomatitis (Canker Sores): Recurrent, painful ulcers without vesicular phase or systemic symptoms.
  • Herpangina: Caused by enteroviruses, with vesicular lesions primarily on the posterior oropharynx and high fever.
  • Primary HIV Infection: Can present with oral ulcers, though other systemic signs are usually present.
Investigations
  • Usually Clinical Diagnosis: Based on history and physical examination.
  • Viral Culture or PCR: Can confirm HSV-1 infection, though often not necessary unless diagnosis is uncertain.
  • Tzanck Smear: May show multinucleated giant cells but is less commonly used.
Management
  • Supportive Care:
    • Analgesics (e.g., paracetamol, ibuprofen) for fever and pain relief
    • Topical anaesthetics (e.g., lidocaine gel) for oral pain
    • Encourage adequate hydration; consider intravenous fluids if oral intake is insufficient
    • Soft, non-irritating diet to reduce pain with eating
  • Antiviral Treatment:
    • Indication: Consider in severe cases or in immunocompromised patients
    • First-Line: Acyclovir, initiated within 72 hours of symptom onset, may reduce severity and duration
  • Consider Referral:
    • If symptoms are severe or complications arise (e.g., dehydration, secondary bacterial infection)
    • In cases of recurrent herpes stomatitis for consideration of long-term antiviral prophylaxis
Complications
  • Acute: Dehydration, secondary bacterial infection of oral lesions
  • Chronic: Recurrent herpes labialis (cold sores), which may occur in later life
  • Severe: Disseminated herpes infection in immunocompromised individuals
Prognosis
  • Primary Infection: Self-limiting with full recovery in 1-2 weeks. Lesions heal without scarring.
  • Recurrent Herpes: Milder and shorter in duration, usually confined to the lips (cold sores).
Prevention
  • Avoid close contact with individuals with active HSV-1 lesions.
  • Good hand hygiene, especially after touching lesions.
  • Consider antiviral prophylaxis in high-risk patients with frequent recurrences.