Christopher is a 35-year-old WM who presents to your office with chief complaints of nasal stuffiness with He requests a course of antibiotics.
PMI- He describes mild right facial discomfort for which acetaminophen has provided no relief. He has no toothache., yellow nasal drainage, watery eyes, nonproductive cough, sore throat, and muscle aches for 7 days’ duration, occasional chills and sweats but has not taken his temperature, at least one or two “sinus infections” every year, and he cannot seem to get over them unless he takes an antibiotic
ROS-. Denies any history of heart or lung disease. Review of systems is otherwise unremarkable.
PMH- hypertension, no history of asthma or hay fever
SH- married and works as a sales manager in a department store for the past 3 years. He and his wife each smoke two packs of cigarettes per week.
Meds- atenolol, no history of drug allergies
VS 146/92 mm Hg, T 98.7 oral, P 78, R 16, O2sat 98%
Physical Examination- in NAD. His conjunctivae are injected. slight maxillary sinus tenderness on the right, and bilateral yellow nasal discharge., normal light transmission through both maxillary sinuses on transillumination. Oropharynx is mildly erythematous and is without exudate. His external ear canals are without edema or erythema and tympanic membranes are neither bulging nor retracted; the ear landmarks are easily identifiable. He has no lymphadenopathy. Heart- RRR without mummur, Lungs-CTA A&P
- What will you include in your physical assessment of Christopher?
- What clinical findings are most useful for making the diagnosis of acute rhinosinusitis?
- What, if any, laboratory/diagnostic tests will you order? Why?
- What would be included in your differential diagnosis?