A 7-year-old boy is brought to the clinic by his mother for evaluation of rhinorrhea. Three days ago, the patient developed rhinorrhea and a cough that is worse at night. For the past day, he has had intermittent, mild pain around the upper cheeks, particularly when leaning forward. He had fever on the first day of illness but has been afebrile for 48 hours. The patient's appetite is decreased, but he is drinking fluids and voiding normally. He has no chronic medical conditions and takes no medication. Immunizations are up to date. Temperature is 37.6 C (99.7 F), pulse is 100/min, and respirations are 20/min. The patient is well-appearing and comfortable on examination. The tympanic membranes are clear. Nasal discharge is profuse and yellow-green in color. The posterior oropharynx is erythematous. Palpation over the upper cheeks bilaterally causes mild discomfort. Cardiopulmonary examination is unremarkable. The abdomen is soft with no organomegaly. Which of the following is the best next step in management of this patient?

Question

A 7-year-old boy is brought to the clinic by his mother for evaluation of rhinorrhea.  Three days ago, the patient developed rhinorrhea and a cough that is worse at night.  For the past day, he has had intermittent, mild pain around the upper cheeks, particularly when leaning forward.  He had fever on the first day of illness but has been afebrile for 48 hours.  The patient's appetite is decreased, but he is drinking fluids and voiding normally.  He has no chronic medical conditions and takes no medication.  Immunizations are up to date.  Temperature is 37.6 C (99.7 F), pulse is 100/min, and respirations are 20/min.  The patient is well-appearing and comfortable on examination.  The tympanic membranes are clear.  Nasal discharge is profuse and yellow-green in color.  The posterior oropharynx is erythematous.  Palpation over the upper cheeks bilaterally causes mild discomfort.  Cardiopulmonary examination is unremarkable.  The abdomen is soft with no organomegaly.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d658_4a07_bc81_49754b804e6a_MD0003_00 This afebrile patient with 3 days of purulent nasal discharge and mild pain with palpation of the maxillary sinuses likely has acute viral rhinosinusitis. Rhinosinusitis is a common infection of the upper respiratory tract characterized by inflammation of the nasal passages and paranasal sinuses. Presenting symptoms include nasal congestion and/or purulent discharge in addition to facial pressure/pain that is exacerbated by leaning forward (as seen in this patient). Pain with palpation or percussion of sinuses is common. Additional symptoms may include fever, cough, headache, ear pain, and loss of smell. Viral rhinosinusitis can be differentiated from bacterial rhinosinusitis by the duration and severity of symptoms. History suggestive of a viral etiology includes mild symptoms (eg, no fever or early resolution of fever, mild pain) and improvement by day 5-10. In contrast, the clinical course of bacterial rhinosinusitis is one of the following: severe in onset (ie, high fever for ≥3 days), persistent (ie, symptoms lasting ≥10 days without improvement), or biphasic (ie, recurrent fever after initial improvement). Management of viral rhinosinusitis is supportive care, including intranasal saline, saline irrigation, and nonsteroidal anti-inflammatory drugs. (Choice A) Antihistamines treat allergic rhinitis, which presents with clear rhinorrhea, congestion, nasal itching, sneezing, and watery eyes. Although allergic rhinitis can be a predisposing factor for rhinosinusitis, this patient's purulent nasal discharge suggests an infectious etiology. (Choices B and D) Inhaled bronchodilators (eg, albuterol) and oral glucocorticoids are indicated in asthma exacerbations, which present with wheezing and shortness of breath. Neither are indicated in rhinosinusitis, although intranasal corticosteroids can be considered in patients with underlying allergic rhinitis to decrease inflammation. This patient's lung examination is unremarkable, and he has no history of atopic disease. (Choice C) Antibiotics (eg, amoxicillin, amoxicillin-clavulanate) are indicated for acute bacterial rhinosinusitis. This well-appearing patient is afebrile with mild sinus tenderness and a short symptom duration, making viral rhinosinusitis more likely. Educational objective: Acute rhinosinusitis presents with upper respiratory symptoms (eg, rhinorrhea, congestion, cough) and facial pain/pressure, with or without fever. Viral rhinosinusitis is more likely than bacterial rhinosinusitis in patients who are afebrile with mild symptoms that improve within 10 days. Treatment is supportive care (eg, nasal saline/irrigation). References: Saline nasal irrigation for acute upper respiratory tract infections. (http://www.ncbi.nlm.nih.gov/pubmed/25892369) Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. (http://www.ncbi.nlm.nih.gov/pubmed/23796742)

A 7-Year-Old Boy Is Brought to the Clinic by His