Reference no: EM133362768

Sandy is a 64-year-old patient with a 10-year history of recurrent sinusitis. She presents to your primary care clinic today complaining of "head congestion." She also reports that she had a "cold" last week with symptoms of cough and "runny nose." Two days ago, she developed a headache that was "worse" when bending over but improved with Tylenol. She describes the headache as a "3 out of 10" and says it is primarily a "frontal headache." She also reports that her nasal congestion has become worse; she has been blowing her nose even more; and the discharge from her nose has become thicker, with a yellow-green color. She has been taking pseudo-ephedrine for the past 48 hours with little relief of her nasal congestion. She denies tooth pain or pain on chewing. She has no past history of seasonal allergies, although she was treated for sinusitis 6 mo ago in your clinic as well as approx. 1 yr ago.

The remainder of her medical history is essentially negative. Her temp taken at the clinic is 99.6°F. On physical examination, she has tenderness to palpation in the frontal area, no maxillary tenderness, nasal mucosa is erythematous as is her pharynx. Her submaxillary nodes are enlarged bilaterally, but there is no cervical lymphadenopathy. Her lungs are clear to auscultation. Her heart has a regular rate and rhythm and is negative for murmurs, gallops, and rubs. Her vital signs are: blood pressure: 128/88; Pulse: 78 and regular; Respiratory rate: 20 p/min, non-labored.

1. What is your assessment of Sandy? Ask about the 10-year history of recurrent sinusitis. Has she ever seen an EENT MD for a discussion about surgery, or is she just treating each episode as it occurs?

2. What is your plan of treatment? Are there any nonpharmacologic treatments that she could try? Did you discuss the use of a neti pot when she is over this episode?

3. Be sure to review the literature on sinusitis. What symptoms and signs are most indicative of a diagnosis for sinusitis? Which are not? How many of these symptoms/signs does Sandy have?

4. What are some other things you might do to better assess Sandy? Do you need to run any diagnostic tests? Why or why not? Has she ever had any X-rays? What do the x-rays and CT scans usually show? Are these necessary if she's not going to have surgery?

5. What are your therapeutic options? Do you prescribe antibiotics to Sandy? If you do, which antibiotics will you prescribe and at what dosage? What instructions will you give Sandy about the antibiotics? Do you continue the use of the decongestant? Why or why not? What other options do you have for relief of her nasal symptoms? Antibiotics are significantly overprescribed for rhinosinusitis, which is the fifth leading indication for antimicrobial prescriptions. Discuss viral versus bacterial infections. What are the different presentations? Which organism is involved if it is bacterial?

6. What follow-up do you need to do on Sandy? Have a discussion on what to do if a patient is insistent on receiving an antibiotic prescription, even when it may not be indicated.