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An 18-year-old female complains of maxillofacial pain. She states that her jaw and right side of her face are 'painful'. She has been afebrile and has had a cold for several days. She has had a minor cough, but contributes her symptoms her cold. She has been eating ok and her activity has been essentially normal. Her medical history is significant for asthma for which she takes a long acting controller and occasionally uses an albuterol inhaler.
On exam, she has tenderness on palpation over her maxillary and frontal sinus, jaw and pre-auricular areas. Her nasal mucosa are red and inflamed. Her right tympanic membrane is red and bulging. Her lungs are clear, however she has a productive cough.
1. List the top three differential diagnosis as well as the most likely cause of this patient's symptoms. Include a brief rationale for each of the differential diagnosis based on the presenting clinical scenario.
2. What adjunct therapies should you consider given her medical history?
3. What is the plan of care for this patient? Please include pharmacology, follow up, etc.
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