Provisional diagnosis:

Common cold (Acute Coryza)

This is highly infectious Upper Respiratory Tract Infection.
Common viral causes are:
Rhinovirus
Coronavirus
Parainfluenza
Respiratory Syncytial Virus
Adenovirus
Influenza
Typical clinical features:
Malaise and tiredness
Sore, runny nose
Sneezing
Sore throat
Slight fever
Other possible symptoms : headache, cough and
hoarseness of voice

Differential Diagnosis

Acute Bronchitis

Dengue

Streptococcus B infection

Serious Infection not to be missed:

Pneumonia

Influenza

Tuberculosis

Red flags of fever

High fever

Altered mental state

Repeated rigors

Incessant vomiting

Drenching night sweats

Unexplained rash

Severe myalgia (sepsis)

Jaundice

Severe pain anywhere (sepsis)

Marked pallor
Severe sore throat or dysphagia
Tachycardia
(Haemophilus influenzae epiglottitis)
Tachypnoea

Investigation

Full Blood Count

Wbc: 4.8x10^3

Rbc: 4.8x10^3

Hb: 12.7g/dL

Hct: 39.6%

Plt: 244x10^3

Lym: 23.1%

Lym count: 1.1 x 10^3

Lorem
Lorem Ipsum
Ipsum Dolor
Dolor

Management

Reassurance

Explain to the patient that her condition is most likely

viral and antibiotic is unnecessary. Reassure her it is not
a serious condition and is self limiting.
Medication will be given to relieve her symptoms.

Advice

Take plenty of rest.

Gargle with aspirin saline to soothe the pain.

Keep well hydrated by drinking plenty of water.

Compliant to the medication given.

Try to stay at home and not go to crowded areas.

Wear mask to prevent from infecting others.

Prescription

Based on the McIsaac Score, antibiotics should be prescribed to patients with a

history of sore throat if the sore is < 2

Therefore in the case of Ms J , she was prescribed with

T. PCM 1g tab x5/7

T. Lovatidine 10mg 5/7

Syp. Benedryl 10ml ON

Medical Certificate is offered for 1 or 2 days.

Referral: No referral is necessary.

Investigation: Full Blood Count was done.

Observation: Inform patient to come back to the clinic if

her condition worsen or the fever did not subside.
Prevention:

1. Achieve ideal weight with Lifestyle modification

2. Health check up for hypertension and diabetes mellitus
3. PAP smear