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LEARNING OBJECTIVES

After completing this case study, the reader should be able to:

  • Compare and contrast the signs and symptoms of acute viral and bacterial rhinosinusitis in a given patient, noting the cardinal symptoms of acute rhinosinusitis.

  • Differentiate viral from bacterial etiology in rhinosinusitis based on a patient’s symptoms.

  • Identify the most common pathogens causing acute bacterial rhinosinusitis.

  • Identify adult patients with a diagnosis of acute bacterial rhinosinusitis who may be candidates for observation without use of antibiotics.

  • Formulate a treatment plan for a patient with acute bacterial rhinosinusitis based on duration of symptoms, severity of symptoms, and history of previous antibiotic use.

  • Revise the treatment plan for a patient who fails the initially prescribed therapy.

PATIENT PRESENTATION

Chief Complaint

“I feel awful and congested, and my head hurts. I was starting to feel better, but now I think my sinus infection is back.”

HPI

Kyle Rheinhardt is a 54-year-old man who presents to his primary care physician with fever, purulent nasal discharge from the left naris, facial pain (L > R), nasal congestion, headache, and fatigue. He states that his symptoms of runny nose, congestion, fever, and malaise began 8 days ago, and the symptoms initially improved over the first 4–5 days. However, the symptoms have become progressively worse over the past few days. He also complains of intense facial pressure when he bends forward to tie his shoes or to pick up something. He has noticed a decreased ability to smell and states that foods do not taste the same as before. He has experienced occasional episodes of nausea, dizziness, tremors, and palpitations for the past week, and states that he has difficulty sleeping the past few nights. He has been taking ibuprofen as needed and loratadine 5 mg/pseudoephedrine sulfate 120 mg every 12 hours but has received little relief from his symptoms. Mr Rheinhardt states that he was treated for a sinus infection about 4 weeks ago. When questioned further, he states that he presented to an urgent care clinic complaining of a runny nose, congestion, sneezing, cough, and a mild sore throat for 2–3 days. He was leaving the following day for a business trip and asked the physician for an antibiotic prescription. He told the physician that azithromycin has always worked for him, so he was prescribed azithromycin 500 mg PO daily for 3 days. His symptoms slowly improved over 7–10 days, and he was symptom-free for a several days before his current symptoms began 8 days ago. He states that he only gets sick occasionally and has not had an infection in the past year prior to these episodes.

PMH

Sinus infection 4 weeks ago

Hypertension (well ...

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