Chief Complaint: Facial Pain
History of Present Illness:
A 40 y.o. female comes to the clinic for a recheck following a 10-day course of antibiotics for sinusitis. She states that the fever has dissipated, but she continues to have pressure and stuffiness over the right eye. Her mucus is thick yellow, but she has no green or bloody mucous. HA is relieved by Tylenol or Advil. She has been using nasal spray and decongestants with minimal relief. She denies ST, cough, or sneezing as well as dental pain or sores of the gums.
Past Medical History
Allergies to trees, grasses, and molds per allergist
Frequent sinus infections likely related to allergies
TAH for fibroids in 2011
Tympanostomy tubes from age 4 to7, then removed
NKDA
Current Meds
Flonase Nasal Spray—two sprays each nostril BID
Mucinex D 600 mg Q12h
Family History
Father, age 75, HTN, tobacco use
Mother, age 72, hypothyroidism secondary to hyperthyroidism with RAI ablation
Sister, age 38, good health
Psychosocial History
Lives in single family home with husband and two children, ages 15 and 12. Nonsmoker and works as an office manager in nonsmoking environment. Exercises three to four times weekly for one hour. Occasional ETOH.
Review of Systems
General: Denies weight loss, fever, weakness, fatigue.
HEENT: Had allergy testing and received allergy shots for 3 years with some success. Has postnasal drip, which is worse in fall and spring. Admits to frequent colds and sinus infections.
CV: Denies HTN, chest pain, palpitations, murmur, edema, abnormal EKG.
Respiratory: Denies chronic cough, SOB, DOE, paroxysmal nocturnal dyspnea, hemoptysis, history of asthma, emphysema, pneumonia, TB.
Neuro: Admits to HAs and occasional dizziness with sinus infections and “allergy attacks.” Denies fainting, seizures, tremors, loss of consciousness, numbness or tingling.
Physical Examination
Vital signs: T 98.8, BP 117/78, HR 76, RR 16, BMI 25.
General: Pale, somewhat listless, cooperative, no acute distress.
HEENT: Posterior pharynx without inflammation, tonsils 1+. Nasal mucosa boggy with thin yellow discharge. Right frontal sinus slightly tender on firm palpation. Maxillary sinuses nontender. TMs shiny with good light reflex, canal without inflammation. Vision 20/25 OD, 20/20 OS. External ocular structures without inflammation, conjunctiva light pink, PERRLA, EOMs parallel with no nystagmus, peripheral vision full in all eight fields. Retina and disc clear, no papilledema, hemorrhages, A-V changes.
Neck: No lymphadenopathy, thyroid not enlarged.
CV: RR&R, no murmurs, clicks, snaps, splits. Peripheral pulses 2+ bilaterally, no temporal artery tenderness. No peripheral edema.
Respiratory: Clear A&P, no adventitious sounds. Percussion resonant throughout.
Neuro: CNs I to XII intact. Alert and oriented x 4. No nuchal rigidity. Immediate and remote memory accurate. Romberg negative. Motor 5/5 in all extremities. Stereognosis and proprioception appropriate.
Case Study Part I:
Answer the following and post your response in the Case Study Part I by creating your own thread.
Identify three conditions that you would consider in your differential diagnosis, with the most likely condition listed first. Provide rationale for each differential with supporting evidence from the case study.
What further history, further examination, and diagnostic studies should be considered in order to explore your differential diagnosis and confirm your suspicions?
Identify three conditions that you would consider in your differential diagnosis, with the most likely condition listed first. Provide rationale for each differential with supporting evidence from the case study.
Differential Diagnosis:
| Differential diagnosis | Rationale |
| Allergic rhinitis | itching, sneezing, nasal obstruction and history of allergies to trees and molds concludes this. |
| Vertigo | Postnatal drip associated with nasal obstruction and congestion relived through decongestion, dizziness associated with sinus infection |
| Nasal polyps | Right frontal sinus tender, yellow discharge, facial pain nasal obstruction all prove this. |
What further history, further examination, and diagnostic studies should be considered in order to explore your differential diagnosis and confirm your suspicions?
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