Voiceover: Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So, if you're ready, let's jump right in.
Margaret Fitzgerald: A 29-year-old otherwise healthy adult presents with a 5-day history of nasal congestion, clear to white rhinorrhea, sore throat, and dry cough. Also denies dyspnea, pleuritic chest pain, GI upset or fever. The patient is in no acute distress. Vital signs are temperature 99.2 Fahrenheit or 37.3 degrees centigrade, respiratory radius 16, O2 sat is 98% on room air. Physical exam reveals mild pharyngeal erythema without exudate. No lymphadenopathy and tympanic membranes are within normal limits. Lung exam is unremarkable except for occasional cough. The nurse practitioner diagnoses a viral URI or a common cold. The patient states, “I have a trip coming up in 5 days and I'm really worried that I might have the start of a sinus infection or pneumonia or a strep throat.”
The NP considers which of the following in addressing the patients concerns.
A. If you start to cough up phlegm within the next day or so, this could indicate the start of a pneumonia.
B. If your nasal discharge turns to green or dark yellow, this usually indicates that an antibiotic is needed.
C. Your cough could persist for a couple of weeks, which is quite common in a viral respiratory tract infection.
D. If your sore throat persists for 2 to three more days, it means that a strep infection is starting.
The correct answer is C. Your cough could persist for a couple of weeks, which is common in viral respiratory tract infection.
Where do you start with this question? First, determine what kind of a question it is given that the patient is asking for advice with a viral respiratory tract infection. This is a plan/intervention question.
A bit of background information. A variety of viruses can cause viral URI with the most common being adenovirus and rhino virus. Of course, additional viruses that can cause what at least looks like the common cold at their onset can include SARS CoV2 infection as well as RSV and influenza. Viral URIs are incredibly common and it's estimated that particularly during the winter months up to 5% of the US population can have a viral URI at any given time. One estimate is there are about 140 million provider visits per year in the US that then the visit is coded for viral URI. I'll tell you there are some winter days where I feel like I saw all 140 million of those provider visits in just an 8 hour shift. But it does vary throughout the year.
What we have here is a typical presentation of a viral URI in an otherwise well younger adult. Treatment is of course supportive and advising the patient how to manage symptoms is the main focus of what we should be doing. This patient is about day five into the cold which is often a turning point in a viral URI.
Now, you might be thinking to yourself, "Yeah, it's just a cold." But common diseases occur commonly. What's going to show up on your NP boards? There will be, I could almost write you a guarantee, at least one question where the patient is presenting with a viral URI. At least one. And what you need to know is out in primary care in the day-to-day, how do viral URIs unfold? You also need to remember that you have the lived experience because no doubt you've had colds yourself.
An uncomplicated viral URI actually has a pretty predictable pattern. The early phase usually includes the following. Days 1 to three, gradual onset of symptoms of sore throat, sneezing, mild malaise, kind of a body ache, you just don't feel that great, you're tired, and nasal congestion with clear rhinorrhea.
On days 3 to five, usually the symptoms peak. By the way, greatest contagion with peak of symptoms with nasal congestion, post-nasal drip, and rhinorrhea usually being what people will report as most bothersome at that time.
Day 5 to 10 are usually marked by overall improvement with sore throat usually resolved and nasal stuffiness and discharge resolving. Even without complication, the cold with a viral URI is usually the last thing to resolve and it can take 2 to three weeks to clear up, but usually without congestion or sputum production. Sputum production might be noted in a person who is a smoker that is not mentioned in this scenario.
At any point in a viral URI, the significant fever is uncommon. The presence of higher fever, significant dyspnea, hypoxemia, and worsening signs and symptoms that occur after a number of days of improvement could be indicative of URI complications. When a person develops unilateral facial pain accompanied by congestion and purulent nasal discharge that begins 10 or more days after URI onset, that could be indicative of bacterial sinusitis. At the same time, please remember that less than .5 to 1% of adults with a viral URI develop a superimposed bacterial infection. I cannot emphasize that enough. and a very serious complication such as a bacterial pneumonia as a complication of a viral URI in a younger adult such as we have here is extremely rare. In fact, in more than three and a half decades of practice where about 40% of my practice is same day urgent care visits. I have never seen that happen.
Let's circle back with this information in mind. Take another look at the question. A 29-year-old otherwise healthy adult presents with a 5-day history of nasal congestion, clear to white rhinorrhea, sore throat, and dry cough, and denies dyspnea, pleuritic chest pain, GI upset, or fever. The patient is in no acute distress, temp 99.2, Fahrenheit or 37.3 centigrade. Respiratory rate is 16 breaths per minute O2 sat 98% on room air. Physical exam reveals mild pharyngeal erythema without exudate without lymphadenopathy and tympanic membranes are within normal limits. Lung exam is unremarkable except for occasional cough. The NP diagnoses a viral URI or common cold. The patient states, "I have a trip coming up in five days, and I'm really worried that I might have the start of a sinus infection or pneumonia or a strep throat.” The NP considers which of the following when addressing the patient's concerns.
A. If you start to cough up phlegm within the next day or so, it could indicate the start of pneumonia. This is of course incorrect. On the rare occasion that bacterial pneumonia complicates viral URI in a younger adult, it would be 10 or more days after the onset of the URI. Take a look at how the question is worded. It says if within the next day or so, so in other words, day six to seven of the URI, if they if the person starts to cough up phlegm, it could indicate the start of pneumonia. That would be not how on the extraordinarily rare occasion that pneumonia follows a viral URI in a younger healthy adult like this. It won't kick in at day six to seven. And the other part to remember, coughing up a little bit of phlegm towards the end of a viral URI is not at all uncommon even for people who are not smokers. Another part, if you were thinking of pneumonia as a viral URI complication, you'd expect fever, dyspnea, perhaps pleuritic chest pain. Keep in mind the boards tend not to test on the extraordinarily unusual complications of an illness such as a pneumonia in the follow-up to a viral URI in a younger adult.
B. If your nasal discharge turns green or dark yellow, it usually indicates an antibiotic is needed. Let's unpack this one because this is a very common misbelief among patients and indeed health care providers. Acute bacterial rhinitis diagnostic criteria includes persistence of viral URI like symptoms 10 or more days after the onset of illness. It is common for individuals with viral URIs to have greener nasal discharge which does not mean bacterial burden but more white blood cell infiltration. In fact, I use this, if you will, of a selling point that the patient doesn't need an antibiotic because their immune system has gone into their sinuses and caused their nasal discharge to use yellow or green because it's doing a great job of fighting off the virus.
C. Your cough could persist for a couple of weeks, which is quite common in viral respiratory tract infection. This is of course the correct answer. You might say, well then would it be an acute bronchitis? And typically, acute bronchitis is not diagnosed until the cough has persisted upwards to 2 to 3 weeks post onset of viral URI symptoms.
D. If your sore throat persists for two or three more days, that means strep infection is starting. Bacterial pharyngitis is quite uncommon in viral URI and so of course this is not the correct answer and when bacterial pharyngitis occurs as an overlap to a viral URI it shouldn't be looked at as a complication. It should be looked at as just a separate illness.
So, could a person with a viral URI then come down with a strep throat? Absolutely. But strep throat just happen to come along in the poor person who already had a cold. Indeed, sore throat is usually one of the first viral URI symptoms to resolve.
Key takeaway. One of the most common illnesses that you will see in primary care is viral URI. As a result, this will be reflected on the NP boards. Knowing how common illnesses unfold is critical to providing patients with helpful counseling.
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