Greenish/Thick Sputum and Nasal Discharge

What does it mean?

Most Likely Diagnosis: Acute Rhinosinusitis (ARS)

Defining symptoms (per American Academy of Otolaryngology guidelines):

• Cardinal signs: Purulent (non-clear) nasal drainage + nasal obstruction AND/OR facial pain/pressure/fullness
• Additional: reduced sense of smell, tooth pain, halitosis, headache, sinus pressure on bending forward, fever
• Duration: 7 days to 4 weeks (acute); beyond 12 weeks = chronic

Viral vs. Bacterial - Key Distinction

• Textbook of Family Medicine 9e, p. 422
• Rosen's Emergency Medicine, p. 969

Note: 80% of patients on placebo still improve within 2 weeks, so most cases are self-limiting regardless of purulence.

Common Bacteria in Acute Sinusitis

1. Streptococcus pneumoniae (most common)
2. Haemophilus influenzae
3. Moraxella catarrhalis (~20% of cases)

Treatment

• Nasal saline irrigation - reduces symptom severity
• Intranasal corticosteroid spray - may shorten illness duration
• Topical decongestants (e.g. oxymetazoline) - max 3 days only, to avoid rhinitis medicamentosa
• Avoid routine antibiotics unless bacterial criteria are met

• First-line: Amoxicillin 500 mg PO three times/day x 5-7 days
• Penicillin allergy: Macrolides, cephalosporins, or fluoroquinolones
• Recent antibiotics (last 4-6 weeks) or treatment failure: High-dose amoxicillin-clavulanate OR a fluoroquinolone
• Plain sinus X-rays and CT are NOT needed for uncomplicated ARS

When to Worry - Complications of Sinusitis

• Periorbital swelling/redness or proptosis (orbital cellulitis/abscess)
• Vision changes
• Severe or worsening headache
• High fever
• Altered mental status (intracranial extension - meningitis, brain abscess, cavernous sinus thrombosis)

• Textbook of Family Medicine 9e, p. 422
• Tintinalli's Emergency Medicine, p. 1620

Other Causes to Consider

• Acute bronchitis - usually viral; antibiotics rarely needed
• Community-acquired pneumonia - if fever, pleuritic chest pain, crackles on auscultation
• Acute exacerbation of COPD/chronic bronchitis - purulent sputum is one criterion (Anthonisen criteria)
• Cystic fibrosis - in younger patients with recurrent episodes

Small, Frequent, Loose Orange-Yellow Watery Stools in a 3-Year-Old

Most Likely Cause: Toddler's Diarrhea (Functional Diarrhea of Childhood)

• Age: 1-4 years
• Multiple (3-6+) small, loose/watery stools per day
• Orange or yellow color, often containing undigested food particles
• Child is well-appearing, gaining weight normally, no blood/mucus
• No pain, no fever, no failure to thrive

Why Orange-Yellow Color?

Differential Diagnosis

1. Acute Infectious Gastroenteritis (most common overall cause of diarrhea at this age)

• Viral (rotavirus, norovirus, adenovirus): watery, yellow-green stools, often with vomiting, low-grade fever; self-limiting
• Bacterial (Salmonella, Shigella, Campylobacter, E. coli): more likely if stool has blood/mucus, high fever, or child appears ill
• Parasitic (Giardia): chronic/recurrent greasy, foul-smelling, pale/yellow stools; bloating; weight loss

2. Toddler's Diarrhea / Functional Diarrhea

• Chronic (>4 weeks), no weight loss, well child, often yellow-orange with food particles

3. Carbohydrate/Lactose Intolerance

• After viral GI illness (secondary lactase deficiency)
• Explosive, frothy, acidic, yellow stools; diaper rash common
• Improves after removing lactose/dairy

4. Food Allergy / Intolerance

• Cow's milk protein allergy; can cause chronic loose stools
• Often with skin (eczema) or respiratory symptoms

5. Celiac Disease

• Chronic, pale/yellow, bulky, fatty stools (steatorrhea); failure to thrive; abdominal distension
• Usually presents after gluten introduction

6. Cystic Fibrosis

• Greasy, bulky, foul stools (steatorrhea); recurrent respiratory infections; failure to thrive

Red Flags - Needs Urgent Evaluation

• Blood or mucus in stool
• Fever ≥39°C
• Signs of dehydration: sunken eyes, dry mouth, no tears, decreased urine output, lethargy
• Failure to thrive / weight loss
• Bilious (green) vomiting
• Abdominal distension or pain
• Diarrhea lasting >2 weeks without improvement
• Tintinalli's Emergency Medicine, p. 884-888
• Rosen's Emergency Medicine, p. 3389-3409

Management

For acute gastroenteritis / mild diarrhea (no red flags):

• Continue feeding - do NOT starve the child; resume normal diet early
• Oral rehydration therapy (ORT) - small frequent sips of oral rehydration solution (ORS like Pedialyte); NOT plain water, NOT sugary juices (worsen diarrhea)
• Continue breastfeeding if applicable
• Avoid fruit juice, high-fructose drinks - worsens diarrhea
• Zinc supplementation (in developing country settings) - reduces duration and severity
• Probiotics (Lactobacillus rhamnosus GG, Saccharomyces boulardii) - modest evidence for shortening acute gastroenteritis by ~1 day
• Antibiotics are NOT routinely needed for watery diarrhea

For toddler's diarrhea:

• Reduce fruit juice and high-fructose corn syrup intake
• Increase dietary fat (fat slows transit)
• Normalize fiber intake
• Reassure parents - the child is well, growing, and will outgrow it

Dehydration Warning Signs to Teach Parents:

• Dry lips and mouth
• Sunken eyes
• Not urinating as often / dark urine
• Reduced tears when crying
• Decreased activity or lethargy

Treatment of Gastroenteritis

Core Principle

Step 1 - Assess Dehydration (the most important step)

Step 2 - Rehydration (Treatment Backbone)

Oral Rehydration Therapy (ORT) - FIRST LINE for most patients

• If vomiting: start with 5 mL every 5 minutes, increase gradually as tolerated
• For mild-moderate dehydration: 25-50 mL/kg over 1-2 hours
• A Cochrane review shows ORT = IV rehydration in outcomes, with shorter hospital stays

IV Rehydration - reserved for:

• Severe dehydration / hemodynamic compromise
• Altered mental status preventing safe oral intake
• Persistent vomiting despite ondansetron
• Failure of ORT

Step 3 - Symptom Management

Vomiting - Antiemetics

• Ondansetron (first choice): 0.15 mg/kg up to 8 mg PO or IV - safe, effective, helps facilitate ORT
• Wait 15 minutes after giving before resuming ORT
• Reduces vomiting, avoids IV hydration in many patients

Diarrhea - Antimotility agents

• Loperamide (adults only, NOT children): reduces stool frequency; use cautiously
• Avoid in bloody diarrhea or suspected invasive/toxin-producing infection (e.g., E. coli O157:H7, C. difficile) - antimotility agents can increase toxin contact time and risk of HUS/TTP
• Bismuth subsalicylate (Pepto-Bismol): modest benefit in adults

Probiotics

• Lactobacillus rhamnosus GG and Saccharomyces boulardii - modest evidence, may shorten acute gastroenteritis by ~1 day

Zinc

• Recommended in children in developing countries (reduces duration and severity)
• WHO recommends 10-20 mg/day x 10-14 days in children with diarrhea

Step 4 - Diet / Feeding

• Do NOT fast the patient - early refeeding is recommended
• Return to normal diet as soon as tolerated - including dairy (no need to stop milk)
• Breastfeeding mothers: continue breastfeeding
• Avoid high-sugar foods/drinks and raw foods during illness

Step 5 - Antibiotics (only for specific situations)

Important: Antibiotics for E. coli O157:H7 are contraindicated - they increase Shiga toxin release and the risk of Hemolytic Uremic Syndrome (HUS).

• Rosen's Emergency Medicine, p. 1301-1307

When to Refer / Admit

• Severe dehydration or hemodynamic instability
• Unable to keep oral fluids down after ondansetron
• Bloody diarrhea with systemic signs (fever, prostration)
• Suspected C. difficile (recent antibiotics/hospitalization)
• Immunocompromised patient
• Extremes of age (very young infants, elderly)
• Diarrhea >2 weeks (consider parasites, IBD, other chronic causes)

Prevention / Infection Control

• Thorough handwashing with soap and water (most important - hand sanitizer alone is inadequate for norovirus and C. difficile)
• Rotavirus vaccine (2 oral doses in infants) - reduces rotavirus hospitalization by ~80%
• Food safety: avoid raw/undercooked poultry, unpasteurized milk, contaminated water

Clinical Assessment: 3-Year-Old with Vomiting + Watery Diarrhea + Fever 99.3°F

Diagnosis: Viral Gastroenteritis (most likely)

• Single episode of vomiting (not bilious, not persistent)
• Small, frequent, watery diarrhea (no blood, no mucus described)
• Age 3 years

"Symptoms of norovirus include low-grade fever, anorexia, nausea, vomiting, diarrhea, and abdominal cramps. The disease typically runs its course in 1 to 5 days." - Swanson's Family Medicine Review

Step 1 - Assess Dehydration RIGHT NOW

Treatment Plan

1. Oral Rehydration Therapy (ORT) - Start Immediately

• Give Pedialyte / ORS (not plain water, not juice, not sports drinks, not soda)
• How to give:
  • Start small - 5 mL (1 teaspoon) every 5 minutes
  • If no vomiting after 30 minutes, increase to 10-15 mL every 5 minutes
  • Target: ~1 oz (30 mL) per kg body weight per hour
  • Replace ongoing losses: ~10 mL/kg per loose stool episode
• For a ~14 kg 3-year-old: aim for ~400-500 mL ORS over 4 hours if mildly dehydrated

"The mainstay of treatment is ORT. Fruit juices, carbonated beverages, and sports drinks are inappropriate - high osmolarity worsens stool losses." - Swanson's Family Medicine Review

2. Antiemetic - If Vomiting Continues

• Ondansetron (Zofran): 0.15 mg/kg as a single oral dose
• For ~14 kg child: approximately 2 mg PO (available as 4 mg ODT - can give half)
• Wait 15 minutes after giving before restarting ORS
• Do NOT use promethazine, metoclopramide, or prochlorperazine in children - risk of respiratory depression and extrapyramidal reactions

3. Fever Management

• 99.3°F (37.4°C) is LOW-GRADE - does not necessarily require medication
• If uncomfortable or fever rises:
  • Paracetamol (acetaminophen): 15 mg/kg/dose every 4-6 hours as needed
  • OR Ibuprofen: 10 mg/kg/dose every 6-8 hours (only if child is not dehydrated and tolerating fluids)
• Do NOT give aspirin in children

4. Feeding - Resume Early

• Do NOT starve the child - this prolongs diarrhea
• Resume normal age-appropriate diet as soon as tolerated
• Continue milk/formula - no need to stop dairy
• The old BRAT diet (banana, rice, applesauce, toast) is no longer recommended - too restrictive, not enough calories or fat
• Avoid high-sugar foods and juices during illness

5. Antidiarrheal Medications

• NOT recommended in children (loperamide, etc.) - safety concerns
• No antibiotics needed - this is viral

Monitoring at Home - Watch for These Red Flags

• Tintinalli's Emergency Medicine, p. 889-890

Expected Course

• Viral gastroenteritis in a 3-year-old typically resolves in 1-5 days
• Vomiting usually stops within 24-48 hours
• Diarrhea may persist for 3-7 days even as child improves
• Appetite will be poor for a few days - this is normal
• Gradual return to normal stool frequency over 1 week