MedicineMan99

Family Medicine Attending (DO)
10+ Year Member
Jun 28, 2004
451
108
281
Status
Attending Physician
This is a question that covers a simple topic but is confusing. If a pt. presents with classic common cold symptoms, what would your differential list look like? Can you only write "URI" once? OR can you write "Viral URI" and "Bacterial URI"? Is "sinusitis" included in the term "URI"? If not, can you also write "Viral sinusitis" and "Bacterial sinusitis"? How about rhinitis? Rhinosinusitis? Are they all the same? Overlapping categories?

What would your differential list look like?

Thanks very much!
 

HooahDOc

15+ Year Member
Jun 23, 2003
5,777
858
381
Status
Attending Physician
I always found it hard to come up with broad DDx in presentations that clearly have a very narrow DDx if you consider all of the presenting symptoms.

For what you described, I would put the following


Viral Syndrome
Sinusitis
Allergic Rhinitis
Something crazy that kinda fits

I don't think you can really split hairs with viral vs bacterial, or at least I wouldn't.
 

Proverbs31

10+ Year Member
5+ Year Member
Jan 11, 2008
175
0
0
Northern bound
Status
Resident [Any Field]
see below
 
Last edited:

Proverbs31

10+ Year Member
5+ Year Member
Jan 11, 2008
175
0
0
Northern bound
Status
Resident [Any Field]
YES - you can write Bacterial vs Viral URI because there are tests to differentiate the two and their modality of treatment is different. You certainly dont want to miss a strep pharyngitis and treat for a viral infection due to the long term potential complications of GAS infections (Rheumatic Fever, Glomerulonephritis) One - you would give Antibiotics, the other you do not. So in your A/P: You could write Viral vs Bacterial URI - order Rapid Strep test, CXR (if other symptoms presented - i.e. productive cough, high fever, etc, and you wanted to rule out Pneumonia or other worse differentials - which could be low on differential list, but may be listed.....Am I making sense? You are not limited by tests, but you would also want to be appropriate with your ordering.

I did list both on my real PE and I still would - if someone presented with the typical fever, cough, runny nose, HA, etc...

This would be my differential. I've listed everything just so you can see, but certain things would be more likely or less depending on your presentation. Hope this helps

Assessment (for a teenager to adult presenting with these things)

1. Bacterial vs Viral URI (Cold) [ I actually listed Bacterial as #1 and Viral as #2 on my real PE]
2. Flu
2. Sinusitis (Bact vs Viral)
3. Pharyngitis
4. Bronchitis (if coughing etc)
5. Pneumonia
6. Mononucleosis - can get monospot test...
7. Post -nasal drip (Allergies)

Example Plan: (certain things I would/ would not include- that depending on pt presentation and what I listed as the actual differential - for your sake Im listing every possible plan and in no specific order)

I would get a rapid strep test, pending results may add Abx, encourage drinking lots of fluids and rest, salt water gargle, chloraseptic spray to help with sore throat, mucinex or guafenasin to help with congestion/mucus, cough syrup/meds, [or just write decongestants, antihistamines, cough suppressants and pain relief], OMM- consider rib raising techniques or thoracic pump, CBC, sputum gram stain/culture, CXR, nasopharyngeal swab (r/o influenza), serum mycoplasma Ag,...thats all I can think of right now, but you get the idea. :)

So yes...there's plenty of room to have 3 + diffs on every patient...Remember, you list your most likely up first but you also dont want to miss something that could be very detrimental to the patient and it would be good to let the examiners know that you thought of this and ruled it in or out by such and such....
Good Luck
 

Proverbs31

10+ Year Member
5+ Year Member
Jan 11, 2008
175
0
0
Northern bound
Status
Resident [Any Field]
YES - you can write Bacterial vs Viral URI because there are tests to differentiate the two and their modality of treatment is different. You certainly dont want to miss a strep pharyngitis and treat for a viral infection due to the long term potential complications of GAS infections (Rheumatic Fever, Glomerulonephritis) One - you would give Antibiotics, the other you do not. So in your A/P: You could write Viral vs Bacterial URI - order Rapid Strep test, CXR (if other symptoms presented - i.e. productive cough, high fever, etc, and you wanted to rule out Pneumonia or other worse differentials - which could be low on differential list, but may be listed.....Am I making sense? You are not limited by tests, but you would also want to be appropriate with your ordering.

I did list both on my real PE and I still would - if someone presented with the typical fever, cough, runny nose, HA, etc...

This would be my differential. I've listed everything just so you can see, but certain things would be more likely or less depending on your presentation. Hope this helps

Assessment (for a teenager to adult presenting with these things)

1. Bacterial vs Viral URI (Cold) [ I actually listed Bacterial as #1 and Viral as #2 on my real PE]
2. Flu
2. Sinusitis (Bact vs Viral)
3. Pharyngitis
4. Bronchitis (if coughing etc)
5. Pneumonia
6. Mononucleosis - can get monospot test...
7. Post -nasal drip (Allergies)

Example Plan: (certain things I would/ would not include- that depending on pt presentation and what I listed as the actual differential - for your sake Im listing every possible plan and in no specific order)

I would get a rapid strep test, pending results may add Abx, encourage drinking lots of fluids and rest, salt water gargle, chloraseptic spray to help with sore throat, mucinex or guafenasin to help with congestion/mucus, cough syrup/meds, [or just write decongestants, antihistamines, cough suppressants and pain relief], OMM- consider rib raising techniques or thoracic pump, CBC, sputum gram stain/culture, CXR, nasopharyngeal swab (r/o influenza), serum mycoplasma Ag,...thats all I can think of right now, but you get the idea. :)

So yes...there's plenty of room to have 3 + diffs on every patient...Remember, you list your most likely up first but you also dont want to miss something that could be very detrimental to the patient and it would be good to let the examiners know that you thought of this and ruled it in or out by such and such....
Good Luck