1. Define the chief complaints
   • Since when fever and cold?
   • Fever pattern: continuous/intermittent, maximum temperature, chills/rigors, sweating.
   • Cold symptoms: rhinorrhoea, nasal blockage, sore throat, cough, sputum, body ache, headache.
2. Look for severity or danger signs
   • Breathlessness, chest pain, wheeze, cyanosis.
   • Persistent vomiting, poor oral intake, reduced urine output.
   • Altered sensorium, seizures, severe headache, neck stiffness.
   • Rash, bleeding, severe weakness.
   • In a child: poor feeding, lethargy, fast breathing, chest indrawing.
3. Ask about the past hospitalisation
   • What was the diagnosis then: pneumonia, influenza, dengue, asthma exacerbation, sinusitis, COVID-19, etc.?
   • Duration of admission and treatment received.
   • Any ICU admission, oxygen, nebulisation, antibiotics, antivirals, or complications?
   • Were investigations done? Chest X-ray, blood tests, cultures?
   • Was there complete recovery after discharge?
4. Assess recurrence
   • How many similar episodes? Frequency and interval?
   • Any seasonal pattern or exposure to sick contacts?
   • Recurrent pneumonia, recurrent sinusitis, or recurrent severe infections may suggest an underlying problem such as asthma, chronic lung disease, aspiration, tuberculosis exposure, or immunodeficiency.
5. Relevant history
   • Vaccination history, including influenza/COVID where relevant.
   • History of asthma, allergy, tuberculosis contact, diabetes, HIV/immunosuppression.
   • Drug history and antibiotic use.
   • Smoking/passive smoke exposure and environmental exposures.
   • Travel, mosquito exposure, contaminated food/water if fever is prominent.
6. Differential diagnosis
   • Viral upper respiratory tract infection/common cold
   • Influenza
   • Acute pharyngitis/tonsillitis
   • Acute sinusitis
   • Acute bronchitis
   • Pneumonia, especially if cough, fast breathing, focal chest signs, or hypoxia
   • COVID-19 depending on setting
   • Non-respiratory febrile illnesses such as dengue, malaria, enteric fever, based on epidemiology and associated symptoms
7. Examination expected
   • Vitals: temperature, pulse, respiratory rate, blood pressure, oxygen saturation.
   • General examination: hydration, pallor, rash, lymph nodes, sensorium.
   • ENT examination: throat, tonsils, nasal discharge, sinus tenderness, ear examination.
   • Respiratory examination: work of breathing, wheeze, crepitations, bronchial breathing.
   • Systemic examination as indicated.
8. Investigations: when indicated
   • A simple viral cold usually needs no laboratory test.
   • If severe, prolonged, recurrent, or suspected pneumonia: CBC, CRP as clinically appropriate, chest X-ray, viral testing, blood culture if systemically unwell, sputum testing when indicated.
   • Evaluate recurrent severe infections further if the history supports it.
9. Management principle
   • First assess severity and oxygenation.
   • Supportive treatment for uncomplicated viral illness: fluids, rest, antipyretic such as paracetamol if suitable, nasal saline.
   • Antibiotics are not routine for a common cold.
   • Treat the identified condition, such as pneumonia or asthma exacerbation, if present.
   • Admit or urgently refer if hypoxia, respiratory distress, altered consciousness, dehydration, sepsis features, or inability to maintain oral intake.

History

1. When did the fever start? Was onset sudden or gradual?
2. What is the highest recorded temperature? Is there chills, rigors, or sweating?
3. What are the cold symptoms: rhinorrhea, nasal block, sore throat, cough, sputum?
4. Is cough dry or productive? What is the sputum color and quantity?
5. Is there breathlessness, wheeze, chest pain, hemoptysis, or cyanosis?
6. Are there headache, myalgia, fatigue, vomiting, diarrhea, rash, urinary symptoms, or altered sensorium?
7. Has anyone at home, school, hostel, or workplace been ill?
8. Any recent travel, mosquito exposure, contaminated food/water, or TB contact?
9. Any COVID-19 or influenza exposure/testing? Vaccination status?
10. What exactly happened in the prior hospitalization? Was the diagnosis pneumonia, asthma exacerbation, dengue, influenza, COVID-19, or another illness?
11. Was there ICU admission, oxygen requirement, nebulization, antibiotics, antivirals, or recurrent admissions?
12. Is there a history of asthma, allergic rhinitis, sinusitis, chronic lung disease, tuberculosis, diabetes, heart disease, kidney disease, or immunosuppression?
13. Drug history, allergies, smoking/vaping, and alcohol use?

Examination

1. What are the vital signs: temperature, pulse, respiratory rate, blood pressure, SpO₂?
2. Does the patient look toxic, dehydrated, cyanosed, or in respiratory distress?
3. Examine throat, tonsils, nasal mucosa, ears, and cervical lymph nodes.
4. Respiratory examination: air entry, wheeze, crackles/crepitations, bronchial breathing, percussion note.
5. Look for rash, hepatosplenomegaly, edema, and signs of meningism if indicated.

Differentials

• Acute viral upper respiratory tract infection/common cold
• Influenza
• COVID-19
• Acute pharyngitis/tonsillitis
• Acute bacterial sinusitis
• Acute bronchitis
• Community-acquired pneumonia
• Acute exacerbation of asthma or COPD, if wheeze or prior respiratory history
• Depending on local epidemiology and associated symptoms: dengue, malaria, enteric fever, tuberculosis, etc.

Investigations the examiner may ask for

• CBC with differential count
• CRP, if bacterial infection/pneumonia is suspected
• Pulse oximetry
• COVID-19 and influenza testing when clinically relevant
• Chest X-ray if hypoxia, tachypnea, focal chest signs, significant cough, or suspected pneumonia
• Blood culture only if severe illness/sepsis is suspected, preferably before antibiotics
• Targeted tests for malaria/dengue/urine infection based on history and examination

Management questions

1. Is the patient stable or does the patient require admission?
2. How would you give supportive care: fluids, rest, antipyretic, nasal saline, and symptom-directed treatment?
3. When are antibiotics indicated?
   Answer: not for an uncomplicated viral cold; use only when a bacterial infection such as pneumonia is clinically suspected or confirmed.
4. When would you consider antivirals for influenza or COVID-19?
5. What isolation and infection-control advice would you give?
6. What are the indications for referral/admission?

Red flags

Important history questions

1. Fever
   • Duration, highest temperature, continuous/intermittent
   • Chills/rigors, seizures, rash, poor feeding, vomiting, reduced urine output
2. Respiratory symptoms
   • Runny nose/nasal block, sore throat
   • Cough: dry or productive, duration, worse at night?
   • Barking cough or noisy breathing/stridor?
   • Wheeze, fast breathing, chest indrawing, grunting, apnea, cyanosis
   • Difficulty feeding because of breathlessness
3. Previous episode
   • Exact diagnosis at hospitalization: pneumonia, bronchiolitis, asthma/wheeze, croup, influenza, COVID-19?
   • Oxygen, nebulization, IV antibiotics, ICU/PICU or ventilatory support?
   • Similar recurrent wheezing episodes? Symptom-free intervals?
   • Discharge medications and response to bronchodilator/nebulization
4. Predisposing history
   • Prematurity, low birth weight, congenital heart disease
   • Atopy: eczema, allergic rhinitis, food allergy; family history of asthma
   • Aspiration/choking episodes, foreign-body possibility
   • TB contact, recurrent/prolonged fever, weight loss
   • Immunization status, including influenza and pneumococcal vaccines
   • Daycare exposure, sick contacts, indoor smoke/biomass exposure

Examination viva points

• Assess ABC, general appearance, hydration, sensorium.
• Record temperature, pulse, respiratory rate, SpO₂, weight.
• Look for nasal flaring, grunting, central cyanosis, and chest indrawing.
• Chest: air entry, wheeze, crackles, bronchial breathing, dullness.
• ENT examination: pharynx, tonsils, ears, cervical nodes.
• Look for rash, hepatosplenomegaly, signs of heart disease and nutritional status.

Likely differential diagnoses

• Viral upper respiratory tract infection/common cold
• Influenza or COVID-19
• Viral-induced wheeze or preschool asthma
• Bronchiolitis, although it is more common below 2 years
• Community-acquired pneumonia
• Croup if barking cough and inspiratory stridor
• Acute otitis media/sinusitis
• Tuberculosis or immunodeficiency only if cough/fever is prolonged, growth is poor, or infections are unusually recurrent/severe.

Investigations if child is unwell

• Pulse oximetry is essential.
• CBC/CRP selectively, not routinely for a simple cold.
• Chest X-ray if suspected pneumonia, hypoxia, severe respiratory distress, focal chest signs, or poor response.
• Viral testing when it will affect isolation or treatment.
• Blood culture if toxic/septic or admitted with severe pneumonia.

Key management answer

Red flags requiring urgent referral/admission

• Fast or labored breathing, chest indrawing, grunting, stridor at rest
• SpO₂ low or cyanosis
• Unable to drink/feed, persistent vomiting, markedly reduced urine output
• Lethargy, altered behavior, seizure
• Toxic appearance or suspected sepsis
• Fever/cough improves then worsens, or worsening underlying lung/heart disease

Developmental history of a 3-year-old child

Viva presentation