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Throat, Respiratory & Cardiovascular Disorders

A 25-year-old Hispanic female, computer programmer presents to your clinic complaining of a 12-day history of a runny nose

States that her symptoms began about 12 days ago. She suffers from allergies; she gets a runny nose during the spring-time, pollen season. However, in the winter, her allergies are not a problem.

(BP) 115/75, (P) 89, (RR) 16, (T) 100.4°F (38°C), O2 sat 98% on room air

No signs of acute distress. Patient appears mildly fatigued. She is breathing through her mouth. Breathing easily. Voice has a nasal quality to it.

Ear canals: normal;
EYES: normal;
NOSE: Bilateral erythema and edema of turbinates with significant yellow drainage on the right. Nares: Obstructed air passages

CTA AP&L

Posterior pharynx: mildly injected, scant postnasal drainage (PND), no exudate, tonsils 1+, no
cobblestoning

Regular rate and rhythm, no murmur, S3, or S4

Full Answer Section

Differential Diagnosis: While acute rhinosinusitis is the most likely diagnosis, other potential causes for the patient's symptoms include:

Allergic Rhinitis: Given the patient's history of seasonal allergies, allergic rhinitis should be considered. However, the lack of typical allergy symptoms (itching, sneezing, watery eyes) during the winter months and the presence of yellow drainage suggest a more likely infectious cause.
Viral Rhinitis (Common Cold): While the duration of symptoms is longer than a typical cold, a viral cause cannot be completely ruled out.
Nasal Polyps: Although less likely, nasal polyps could contribute to congestion and drainage. Further investigation would be required to rule this out.

Further Evaluation:

Nasal Endoscopy: To confirm the diagnosis and rule out nasal polyps, a nasal endoscopy might be recommended.
X-ray or CT Scan: If the diagnosis is unclear, an X-ray or CT scan of the sinuses could be performed to assess for inflammation or blockage.
Culture and Sensitivity: If bacterial infection is suspected, obtaining a culture of the nasal drainage could help identify the specific bacteria causing the infection and guide antibiotic therapy.

Treatment Plan:

Decongestants: Oral decongestants, such as pseudoephedrine or phenylephrine, can help alleviate nasal congestion.
Nasal Corticosteroids: Nasal corticosteroids, such as fluticasone or mometasone, can reduce inflammation and improve sinus drainage.
Antibiotics: If a bacterial infection is confirmed, antibiotics, such as amoxicillin-clavulanate or doxycycline, might be prescribed.
Saline Nasal Spray: Saline nasal spray can help clear nasal passages and promote drainage.
Humidifier: Using a humidifier can help thin mucus and ease breathing.
Pain Relief: Over-the-counter pain relievers, such as acetaminophen or ibuprofen, can alleviate headache and facial pain.

Patient Education:

Importance of Hydration: Encourage the patient to stay hydrated to help thin mucus.
Avoid Irritants: Advise the patient to avoid smoke, dust, and other potential irritants that can aggravate sinus symptoms.
Follow-Up: Schedule a follow-up appointment if symptoms persist or worsen.

Sample Answer

Patient Assessment and Potential Diagnosis

Based on the information provided, the patient is likely experiencing acute rhinosinusitis, also known as a sinus infection. This diagnosis is supported by the following:

Duration of Symptoms: The patient reports a 12-day history of symptoms, which is consistent with the typical duration of acute rhinosinusitis.
Symptoms: The patient presents with classic symptoms, including a runny nose, nasal congestion, and yellow drainage.
Fever: The patient's temperature of 100.4°F (38°C) is consistent with a sinus infection.
Physical Examination Findings: The examination reveals bilateral erythema and edema of the turbinates, significant yellow drainage on the right side, and obstructed air passages. This indicates inflammation and infection within the sinuses.