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Department of Internal Medicine

Upper Respiratory Infection

Rationale

Upper respiratory tract infections are some of the most common problems for which patients seek medical attention. Many patients inappropriately receive antibiotic therapy for these mostly viral infections.

Prerequisites

Prior knowledge acquired during the pre-clerkship experience should include:

  • anatomy and physiology of the upper airway, Eustachian tubes, and sinuses.
  • microbial pathogens associated with upper respiratory tract infections (URTIs).
  • pharmacology of antibiotics.

Knowledge

Students should be able to define, describe and discuss:

  • a rational approach to common upper respiratory symptoms: nasal congestion, rhinorrhea, facial pain, cough, sputum production, sore throat, ear pain.
  • common constitutional symptoms that accompany upper respiratory tract infections (URTIs): generalized weakness, fatigue, malaise, headache, mild myalgias, and modest fever.
  • the microbiology of URTIs, highlighting the relative frequencies of viral and bacterial etiologies.
  • the most common microbiologic agents that cause the common URTIs.
  • the pathophysiology and typical clinical presentation of the common URTIs:
    • common cold
    • acute bronchitis
    • pharyngitis
    • acute sinusitis
    • otitis media
  • the pathophysiologic similarities between the common cold and acute sinusitis.
  • the clinical features and microbiology of acute compared to chronic sinusitis.
  • the pathophysiology and symptomatology of allergic rhinitis and the clinical features that may help differentiate it from the common URTIs.
  • the clinical features that help differentiate the common URTIs from influenza.
  • the pathophysiology and clinical features of acute versus chronic bronchitis.
  • the pathophysiology and clinical features of acute bronchitis compared to pneumonia.
  • the pathophysiology and clinical features of otitis media and Eustachian tube malfunction.
  • the signs and symptoms that may help distinguish viral from bacterial pharyngitis.
  • symptomatic treatment for URTIs (and the major side effects and contraindications for these treatments) including:
    • decongestants
    • non-selective antihistamines
    • mucolytics
    • cough suppressants
    • pain relievers/fever reducers
  • the general role of antibiotics in the treatment of URTIs and specific evidence-based indications for them.
  • the basic elements of the treatment of allergic rhinitis.
  • the use of antiviral agents in the prophylaxis and treatment of influenza.

Skills

Students should demonstrate specific skills, including:

  • History-Taking Skills: Students should be able to obtain, document, and present a medical history that differentiates among etiologies of disease including:
    • the predominant symptom -- nasal congestion/rhinorrhea, purulent nasal discharge with facial pain/tenderness, sore throat, cough with or without sputum, sore throat or ear pain
    • constitutional symptoms
    • symptoms of potential pneumonia – fever, rigors, chills, pleuritic chest pain
    • history of or symptoms of serious cardiopulmonary diseases -- e.g., asthma, chronic obstructive pulmonary disease, congestive heart failure -- that may alter the treatment plan

  • Physical Exam Skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease including:
    • examination of the nasal cavity
    • otoscopic examination
    • examination of the pharynx
    • examination of the sinuses for tenderness
    • evaluation of the head and neck for lymphadenopathy
    • auscultation of the lungs to distinguish pulmonary consolidation, pleural effusion, pulmonary congestion, and chronic obstructive pulmonary disease

  • Differential Diagnosis: Students should be able to generate a prioritized differential diagnosis recognizing specific history and physical exam findings that suggest a specific etiology:
    • common cold
    • acute sinusitis
    • chronic sinusitis
    • allergic rhinitis
    • pharyngitis
    • otitis media
    • otitis externa
    • acute bronchitis
    • chronic bronchitis
    • influenza
    • pneumonia
    • infectious mononucleosis

  • Laboratory Interpretation: Students should be able to recommend when to order diagnostic and laboratory tests and be able to interpret them, both prior to and after initiating treatment based on the differential diagnosis including consideration of test cost and performance characteristics as well as patient preferences.
    • Laboratory and diagnostic tests should include, when appropriate:
      • complete blood count (CBC) with differential
      • rapid strep test
      • throat culture
      • chest radiograph
      • pulmonary function testing
      • monospot/heterophile antibody
    • Students should be able to define the indications for and interpret (with consultation) the significance of the results of:
      • sinus CT
  • Communication Skills: Students should be able to:
    • explain the microbiologic origin of most URTIs and why antibiotics are generally ineffective
    • explain the importance of antimicrobial resistance

  • Management Skills: Students should be able to develop an appropriate evaluation and treatment plan for patients that includes:
    • determining when to obtain a chest radiograph.
    • determining when to obtain a sinus CT.
    • determining when to prescribe antibiotics.
    • selecting the most appropriate antibiotic for acute sinusitis, pharyngitis, acute bronchitis, and otitis media.
    • prescribing symptomatic treatments.
    • determining when to obtain consultation from an allergist, otolaryngologist, or pulmonologist.
    • a cost-effective approach based on the differential diagnosis.
    • accessing and utilizing appropriate information systems and resources to help delineate issues related to URTIs.

Attitudes and Professional Behaviors

Students should be able to:

  • discuss the patient’s perspective regarding the use of antibiotics for URIs.
  • discuss the role physicians play in the over-prescribing of antibiotics for URIs.
  • discuss the importance of antimicrobial resistance from the point of view of the individual and society at large.

Resources

  • Johns Hopkins Internet Learning Center
    The password is available in the Clerkship office.
    Select Internal Medicine:Ambulatory Care Curriculum
    Click on "Respiratory Infections" under featured modules
    Take Pretest, Complete Case, and Follow with Post Test
  • Antibiotics for Common Respiratory Tract Infections in Adults, Hirschmann, JV, Archives of Internal Medicine, 2002;162:256-264
  • Does This Patient Have Sinusitis? Diagnosing Acute Sinusitis by History and Physical Examination, John W. Williams, Jr, MD, MHS; David L. Simel, MD. MHS, JAMA, Sept. 8, 1993, Vol. 270, Number 10, pp. 1242-1246.
  • Principles of Appropriate Antibiotic Use for Acute Rhinosinusitis in Adults: Background, Hickner, JM; Bartlett, JG; Besser, RE; Gonzalez, R; Hoffman, JR; Sande, MA, Annals of Internal Medicine, 2001;134:498-505.
  • Principles of Appropriate Antibiotic Use for Treatment of Uncomplicated Acute Pharyngitis in Adults: Background, RE; Cooper, RJ; Hoffman, JR; Bartlett, JG; Besser; Gonzalez, R; Hickner, JM; Sande, MA, Annals of Internal Medicine, 2001;134:509-517.
  • Principles of Appropriate Antibiotic Use for Treatment of Uncomplicated Acute Bronchitis in adults: Background, Gonzalez, R; Bartlett, JG; Besser, RE; Cooper, RJ; Hickner, JM; Hoffman, JR; Sande, MA, Annals of Internal Medicine, 2001;134:521-529.
  • Acute Pharyngitis, NEJM, Vol. 344, No. 3, January 18,2001.

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