A 32-year-old man comes to the physician because of facial pain and fever. He developed a "cold" one week ago with symptoms consisting of mild malaise, sore throat, clear nasal discharge, and productive cough of small amounts of gray sputum. He felt that he was improving, but now has 1 day of fever, chills, purulent nasal discharge, and facial fullness with pain. His pain is worsened by bending over. He also reports aching of his upper left molars. He is in good health, takes no medications, and has no HIV risk factors. He has no known drug allergies.
His temperature is 39.2 C (102.5 F), pulse is 90/min, and respirations are 14/min. He appears uncomfortable. There is pain to light tapping over his left maxillary region. There is swelling of his turbinates and purulent nasal discharge in his left naris. There are no nasal polyps. His pharynx shows no erythema or exudates. Cardiopulmonary examination is within normal limits.
Which of the following is the best next step in management?

Question

A 32-year-old man comes to the physician because of facial pain and fever.  He developed a "cold" one week ago with symptoms consisting of mild malaise, sore throat, clear nasal discharge, and productive cough of small amounts of gray sputum.  He felt that he was improving, but now has 1 day of fever, chills, purulent nasal discharge, and facial fullness with pain.  His pain is worsened by bending over.  He also reports aching of his upper left molars.  He is in good health, takes no medications, and has no HIV risk factors.  He has no known drug allergies.
His temperature is 39.2 C (102.5 F), pulse is 90/min, and respirations are 14/min.  He appears uncomfortable.  There is pain to light tapping over his left maxillary region.  There is swelling of his turbinates and purulent nasal discharge in his left naris.  There are no nasal polyps.  His pharynx shows no erythema or exudates.  Cardiopulmonary examination is within normal limits.
Which of the following is the best next step in management?

Quizplus · Accepted Answer

This patient's presentation is consistent with acute bacterial rhinosinusitis. Most acute sinusitis seen in the primary care setting is viral in origin and is associated with the common cold. There is no evidence that antimicrobial treatment is effective in treating viral sinusitis. However, differentiating between viral and bacterial sinusitis is difficult. Acute bacterial sinusitis should be considered in patients with symptoms > 10 days; severe symptoms with fever > 39 C (102 F), purulent nasal discharge or facial pain > 3 days; or worsening symptoms > 5 days after an initially improving viral upper respiratory infection (Choice C). 11ec193a_979a_4493_853d_d3dc8ed06ff5_MD0002_00 Current guidelines recommend amoxicillin-clavulanate for 5-7 days to treat acute bacterial sinusitis in non-penicillin allergic patients. Amoxicillin is not the drug of choice due to increasing resistance of respiratory pathogens (e.g., Streptococcus pneumonia and Haemophilus influenza). Macrolides (e.g., azithromycin, clarithromycin), trimethoprim-sulfamethoxazole, and 2^nd or 3^rd generation cephalosporins are also not recommended as first-line agents due to increasing resistance involving the same respiratory pathogens (Choices B and E). Doxycycline and respiratory quinolones (e.g., levofloxacin, moxifloxacin) are alternatives for penicillin-allergic patients. Quinolones or high-dose amoxicillin-clavulanate (2000 mg/125 mg) is recommended in patients who fail initial therapy. ^nd ^rd (Choice D) Sinus x-rays are not indicated in acute bacterial sinusitis. CT is preferred over sinus x-rays in patients with acute complicated sinusitis with vision abnormalities (e.g., decreased acuity, diplopia), periorbital edema, severe headache, or altered mental status. CT is also preferred in patients with uncomplicated bacterial sinusitis with persistent or worsening symptoms after antibiotic treatment to evaluate for air-fluid levels, which indicate chronic sinusitis. Educational objective: Acute bacterial sinusitis usually presents with symptoms > 10 days; severe symptoms with fever > 39 C (102 F), purulent nasal discharge or facial pain > 3 days; or worsening symptoms > 5 days after an initially improving viral upper respiratory infection. Amoxicillin-clavulanate for 5-7 days is preferred in non-penicillin-allergic patients. Doxycycline and respiratory quinolones (e.g., levofloxacin, moxifloxacin) are alternatives in penicillin-allergic patients. __________ References: IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. (http://www.ncbi.nlm.nih.gov/pubmed/22438350)

A 32-Year-Old Man Comes to the Physician Because of Facial