Sinusitis

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents with a ‍-‍day history of ‍facial painnasal congestionnasal discharge

Symptoms include:

‍facial pressure

‍nasal congestion

‍nasal discharge, ‍clearcolored

‍headache, ‍diffuse, ‍persistentintermittent, ‍pressurethrobbing, ‍mild

‍fever, up to ‍°, over ‍ ‍hoursdays

‍cough, ‍non-productiveproductive of ‍clearcolored phlegm

‍sputum, ‍clearwhiteyellowgreen

‍sore throat

‍decreased sense of smell

‍fatigue



Worsening factors: ‍none

Alleviating factors: ‍none, ‍effectiveineffective



Contributing factors:

‍smoking

‍recent upper respiratory infection

‍exposure to allergens

‍dry air exposure

no history of: ‍sinusitis, ‍chronic rhinosinusitis, ‍allergies, ‍nasal polyps, ‍deviated septum, ‍immunodeficiency





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Eyes: conjunctiva/sclera ‍normal, lids/lashes ‍normal

Ears: tympanic membranes ‍normal ‍, auditory canal ‍ on ‍rightleft, hearing ‍intact

Nose: ‍clear, discharge ‍clear, ‍

Throat: ‍normal, ‍erythema, ‍exudate, ‍

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍

Skin: ‍rashlesions on ‍





ASSESSMENT:

‍Sinusitis ‍likelysuspectedpossible

DDx: sinusitis, URI, acute sinusitis, chronic sinusitis, fungal sinusitis, allergic rhinitis, nasal polyps, deviated septum, COVID-19, influenza, nasal vestibulitis, dental abscess, foreign body in the nose, rhinitis medicamentosa, sinus tumor, granulomatosis with polyangiitis, sarcoidosis





PLAN:

Investigations:

- CT scan of sinuses

- Allergy testing

Treatments:

- Saline nasal irrigation

- ‍Nasal corticosteroids

- ‍Decongestants

- ‍Antibiotics

- ‍Analgesics

- ‍Antihistamines

Further care:

- Referral to otolaryngologist

- Follow-up in ‍ ‍daysweeks

- Return if symptoms worsen or if new symptoms develop such as severe headache, vision changes, or high fever

- Referral to ER if severe headache, vision changes, or high fever occurs