Doctors: when to come see you

Hello, Doctors. Cold and flu season is on the horizon, and with it, hordes of hypochondriacs who want antibiotics to cure their sniffles… and a few stout-hearted men who don’t come in until they have pneumonia.

Can the medical professionals please chime in on how long each of the following symptoms should be given to “resolve itself” before a person schedules a doctor’s visit?

Head cold
Sore throat
Cough
Any of these combined with fatigue/malaise

Well, I haven’t done a residency but I just finished med school so I’ll give you my general take. Also, very important, this advice relates only to someone who’s normally healthy, not someone taking immune-suppression drugs, someone with known cancer, AIDS, etc… Finally, it goes without saying that you shouldn’t take anything here as gospel, right?? If you’re personally worried, go.

Head cold: When I hear this I think stuffy/runny nose, sore throat, mild/moderate cough, no fever. If this is all you get, there ain’t much we can do except point you to your local drug store for symptomatic relief. Especially the cough, it’s going to hang around for 2-3 weeks (we’ll get to cough soon), it’ll be irritating, but hang tough.

Sore throat: If you’re a child and your throat is pretty red, you have exudate (white pus-looking stuff) at the back of the throat esp. the tonsils, swollen glands in the neck and/or below the chin, and fever, you may well have a strep A infection and you should be treated with an antibiotic – interestingly, not to cure the sore throat but to prevent post-strep complications, most notably rheumatic fever which is uncommon but can damage your heart valves among other things.

If you’re an adult and you have similar symptoms, you may want to see if you have a strep infection so that you can prevent passing it on to a kid, but it’s less important. Either way a strep infection will almost certainly get better on its own. And most importantly, if your symptoms are less severe you very likely have a virus, which is so small that it can’t possibly make off with a whole leg, and we’re at symptomatic relief again – over-the-counter pain meds, either systemic (a pill) or local (cepacol).

Cough: If you’re coughing up blood, go. Especially if you’ve been smoking for a while. Maybe you can get away with a few flecks of blood after a major coughing fit, but keep your eye out.

If you’ve got a high fever (>102F or 39C) for more than a couple of days, you’re coughing up gobs of yellow stuff, and it hurts to breathe, you probably need an antibiotic.

Cough is notorious for lingering on and on…you get a cold, everything else gets better, but you have this irritating cough with maybe a little green gunk that just won’t go away. Well, you probably just have irritated regenerating/healing bronchial tissue, and a doctor won’t be able to fix it, although we have some nice codeine to brighten your day (reduces the urge to cough – or just makes you not care so much?), so if you can’t sleep or control the urge to jump off a tall building because of the goddam cough, we’ll hook you up.

Fatigue/malaise: If you’re a medical intern (as is my wife) and you don’t have these symptoms, I’m calling the DEA on you. Otherwise, this is a tricky one. Surprise surprise, it depends on the severity and duration. It can be caused by everything from anxiety to a urinary tract infection. Basically, if you feel severely fatigued or malaise-y (coined it!) for more that a couple of weeks and you can’t point to an obvious cause, get checked out. If it’s impairing your ability to do things like work, eat, bathe, go. Otherwise you’re very likely to get a pat on the back and similar advice in person.

IAAD but a very junior one, and I work in a hospital. So my advice is only slightly above worthless.

All of the symptoms you have 1-3 are most commonly caused by a viral upper respiratory tract infection. These usually make you sick for around 7-10 days: 2-3 d feeling like crud pre-sickness, 2-3 d sick, 2-3 d recovery. Most don’t cause high fevers, chills, and muscle pain, although flu can. A doctor isn’t going to do anything about these illnesses, although if you are elderly, have comorbid conditions like asthma or lung disease, you may need extra treatment. Even the upper respiratory bacterial infections, like sinusitis and strep throat, often don’t need antibiotics (although this is a source of debate in the literature). Some symptoms, like cough, can take months to completely clear.

Now, if you are knocked on your ass by any of these things, go to the doctor. If you have to miss more than a few days of work, go to the doctor. High fevers, chills, rigors, purulent sputum, go to the doctor. The main thing to be worrying about is pneumonia, which absolutely requires antibiotics. For anything not knocking you on your ass, I would wait a week at least. Honestly, antibiotics do more harm than good in most of these cases. Push fluids, take some Tylenol and Motrin, stay home from work for a few days and watch All My Children. If you find yourself unable to get out of bed after a few days like that, then start thinking about a doctor.

Question: Can’t an adult’s strep infection progress to more serious diseases causing heart valve problems, too? How about scarlet fever? I seem to recall being told that was a “sore throat due to strep” infection issue.

My kids’ pediatrician said that it is very difficult to diagnose a strep vs. viral throat infection without a specific culture, that strep does not always produce the more obvious symptoms.

I think the risk of post-streptococcal complications, including scarlet fever (bad rash) and rheumatic fever (which can cause valvular damage) is greater in kids, not sure why (or if it’s known why, probably not).

You’re right that clinical assessment (i.e., looking and signs and symptoms) is very inaccurate for differentiating strep vs. viral pharyngitis; sensitivity and specificity estimates range from 55 to 74 and 58 to 76 percent, respectively, according to the review site Up To Date. As you say, the only definitive test is a throat culture, though there is a faster, nearly-as-accurate test (the RSAT or rapid strep antigen test).

However, there have been attempts to create clinical criteria to decide which patients to send for further testing. The current concensus is the Centor criteria which include the following: 1) Tonsillar exudate (pus); 2) Tender nodes in the neck 3) Recent/ongoing fever; 4) Absence of cough. Having 3 of 4 of these criteria is generally considered the appropriate trigger further testing, either RSAT or culture. However, the sensitivity and specificity of this prediction rule are 75 percent, not much improvement over the numbers I cited above; even with these criteria it’s estimated that 50% of people who get antibiotics didn’t actually have a strep infection. Inappropriate antibiotic use = death to us all…

I think the risk of post-streptococcal complications, including scarlet fever (bad rash) and rheumatic fever (which can cause valvular damage) is greater in kids, not sure why (or if it’s known why, probably not).

You’re right that clinical assessment (i.e., looking and signs and symptoms) is very inaccurate for differentiating strep vs. viral pharyngitis; sensitivity and specificity estimates range from 55 to 74 and 58 to 76 percent, respectively, according to the review site Up To Date. As you say, the only definitive test is a throat culture, though there is a faster, nearly-as-accurate test (the RSAT or rapid strep antigen test).

However, there have been attempts to create clinical criteria to decide which patients to send for further testing. The current concensus is the Centor criteria which include the following: 1) Tonsillar exudate (pus); 2) Tender nodes in the neck 3) Recent/ongoing fever; 4) Absence of cough. Having 3 of 4 of these criteria is generally considered the appropriate trigger further testing, either RSAT or culture. However, the sensitivity and specificity of this prediction rule are 75 percent, not much improvement over the numbers I cited above; even with these criteria it’s estimated that 50% of people who get antibiotics didn’t actually have a strep infection. Inappropriate antibiotic use will be the death of us…

I’m with you on avoiding antibiotics when not clearly indicated. Our pediatrician NEVER prescribed them unless he had a positive reason for them. I’ve been known to rant at friends, family, co-workers, etc. over trying to get penicillin for a cold.

Mal à l’aise.

As a kid, my mother always took me to the doctor whenever we had a cold, to make sure it wasn’t anything serious. I understand that with a viral cold, I have to stay in bed for a week, and the doctor can only give medication to relieve the symptoms. I also don’t want antibiotics everytime it’s a bacterial cold.

But if I read the above correctly, this only applied to children, and for adults, if it feels like a cold, a visit to the doctor isn’t necessary, because it will only be a cold? Is that right? Just lay down in bed and let it run its course?

Wouldn’t a few days watching All my Children be likely to cause brain damage?

Not in the short run. Tuning it in might actually be beneficial, as after a few days you’ll be desperate to get up and out of the house.

Definitely the timing and amount of followup are related to a person’s general health. And some symptoms ascribed to persistent respiratory infections (cough, malaise, and chest pain for example) can be due to serious underlying problems.