Common Outpatient Complaints

Upper respiratory and allergic complaints

The stewardship mindset. Most URIs, sinus infections, back pain, and dizziness are self-limited. Reserve antibiotics for narrow bacterial criteria, imaging for red flags or 6+ weeks of symptoms, and referral for neurologic deficits or diagnostic uncertainty.

The common cold. Viral URIs are treated supportively with fluids, analgesics, and saline. Purulent or green nasal discharge does not mean bacterial infection and is not an indication for antibiotics: mucus color reflects neutrophils, not bacteria.

Acute rhinosinusitis. About 90–98% of cases are viral. Give supportive care (analgesics, saline irrigation, intranasal steroids) unless one of three bacterial patterns is present. Imaging is not part of the routine workup.

Periorbital swelling, vision change, severe headache, or altered mental status with sinusitis suggests orbital or intracranial spread and needs urgent imaging and IV antibiotics.

Group A strep (GAS) pharyngitis. The Centor criteria are tonsillar exudate, tender anterior cervical nodes, fever, and absence of cough. The McIsaac modification adds a point for age 3–14 and subtracts one for age ≥45. Scores of 0–1 need no testing or antibiotics; in US practice a score of 2 or more warrants a rapid antigen detection test. Treat only positive tests, with penicillin or amoxicillin for 10 days. In children and adolescents, back up a negative rapid test with a throat culture.

Timely penicillin prevents acute rheumatic fever but not poststreptococcal glomerulonephritis. For penicillin allergy, use cephalexin if the reaction was not anaphylaxis, and azithromycin or clindamycin if it was.

Allergic rhinitis. Intranasal corticosteroids (e.g., fluticasone) are the single most effective therapy and first-line for persistent symptoms. Add a second-generation oral antihistamine (loratadine, cetirizine) and allergen avoidance. Avoid sedating first-generation antihistamines in older adults. Limit topical decongestants (oxymetazoline) to about 3 days to avoid rebound congestion (rhinitis medicamentosa).

Low back pain: reassure first, image for red flags

Nonspecific acute back pain. Without red flags, do not image in the first 6 weeks. Early imaging adds cost, radiation, and incidental findings without improving outcomes. Advise staying active (bed rest slows recovery), use NSAIDs first-line (superficial heat and short courses of muscle relaxants are adjuncts), and reassure the patient that most episodes resolve within weeks. Image if symptoms persist beyond 6 weeks or a red flag appears; MRI is the usual study.

• Cauda equina: saddle anesthesia, urinary retention with overflow incontinence, bilateral leg weakness, decreased anal tone
• Cancer: history of malignancy, unexplained weight loss, pain at night or at rest
• Infection: fever or IV drug use (vertebral osteomyelitis, epidural abscess)
• Fracture: major trauma, or minor trauma with osteoporosis or long-term steroid use

Cauda equina syndrome is a surgical emergency: get an emergent MRI and surgical decompression. Urinary retention is the most sensitive early sign. In a patient with cancer, back pain with a new neurologic deficit suggests metastatic cord compression: give high-dose dexamethasone and get an urgent MRI of the whole spine.

Dizziness: peripheral or central?

Sort the vertigo. Peripheral causes (BPPV, vestibular neuritis, Ménière disease) are common and benign; the danger is a cerebellar or brainstem stroke. In acute, continuous vertigo with nystagmus (the acute vestibular syndrome), the three-part HINTS exam separates the two.

In acute continuous vertigo, a normal head impulse test is the worrisome finding because it points to a central (stroke) cause. HINTS is not used for brief positional vertigo: in BPPV the vestibular nerve is intact, so the head impulse test is typically normal.

BPPV. Displaced otoliths (usually in the posterior semicircular canal) cause brief vertigo, under 1 minute, triggered by head position (rolling over in bed, looking up). Diagnose with the Dix-Hallpike maneuver: upbeat-torsional nystagmus after a short latency that fatigues with repetition. Treat with the Epley repositioning maneuver rather than vestibular suppressants.

Other peripheral causes. Vestibular neuritis causes days of continuous vertigo after a viral illness with normal hearing (labyrinthitis adds hearing loss). Ménière disease causes recurrent attacks lasting hours with fluctuating low-frequency sensorineural hearing loss, tinnitus, and aural fullness from endolymphatic hydrops; manage with salt restriction and diuretics.

Fatigue and common musculoskeletal complaints

Fatigue. Fatigue is usually benign and often has several causes. Let the history (sleep, snoring, mood, medications, weight change, bleeding) direct testing. Common reversible causes are depression, anemia, hypothyroidism, obstructive sleep apnea, diabetes, and medications. A reasonable basic evaluation is a CBC, TSH, glucose, and depression screening (PHQ-9). Weight loss, fever, night sweats, or lymphadenopathy warrant a broader search for cancer or infection. Chronic fatigue syndrome is a diagnosis of exclusion: at least 6 months of disabling fatigue with post-exertional malaise and unrefreshing sleep.