A 22-year-old woman comes to the office in April due to sinus congestion. Three weeks ago, she had subjective fever, myalgia, nasal congestion, sore throat, and dry cough a few days after visiting her sick nephew. Her symptoms initially improved with over-the-counter analgesics and decongestants, but she now has had 2 weeks of purulent nasal discharge, throbbing headache, and facial pain. The patient has a history of type 1 diabetes mellitus managed with premeal insulin boluses and an insulin pump for continuous subcutaneous insulin infusion. She also has a history of childhood eczema. She does not use tobacco, alcohol, or illicit drugs. The patient has no known drug allergies. Temperature is 38 C (100.4 F), blood pressure is 118/74 mm Hg, and pulse is 90/min. Physical examination shows swollen and erythematous nasal turbinates with yellowish-green nasal secretions. The left maxillary sinus is tender to palpation, with no sinus transillumination. The tympanic membranes and oropharyngeal mucosa are normal. Cervical lymph nodes are not enlarged or tender and lungs are clear to auscultation. Fingerstick blood glucose is 120 mg/dL. Which of the following is the best next step in management of this patient?

Question

A 22-year-old woman comes to the office in April due to sinus congestion.  Three weeks ago, she had subjective fever, myalgia, nasal congestion, sore throat, and dry cough a few days after visiting her sick nephew.  Her symptoms initially improved with over-the-counter analgesics and decongestants, but she now has had 2 weeks of purulent nasal discharge, throbbing headache, and facial pain.  The patient has a history of type 1 diabetes mellitus managed with premeal insulin boluses and an insulin pump for continuous subcutaneous insulin infusion.  She also has a history of childhood eczema.  She does not use tobacco, alcohol, or illicit drugs.  The patient has no known drug allergies.  Temperature is 38 C (100.4 F), blood pressure is 118/74 mm Hg, and pulse is 90/min.  Physical examination shows swollen and erythematous nasal turbinates with yellowish-green nasal secretions.  The left maxillary sinus is tender to palpation, with no sinus transillumination.  The tympanic membranes and oropharyngeal mucosa are normal.  Cervical lymph nodes are not enlarged or tender and lungs are clear to auscultation.  Fingerstick blood glucose is 120 mg/dL.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bfc0_b266_8f63_27a0b4543304_MD0005_00 This patient had symptoms of a viral upper respiratory infection and then developed 2 weeks of purulent nasal discharge, headache, and facial pain, suggesting acute bacterial rhinosinusitis (ABRS). Acute rhinosinusitis is the symptomatic inflammation of the nasal and sinus mucosa for <4 weeks. The majority of cases are due to viral upper respiratory pathogens (eg, influenza virus, rhinovirus, adenovirus) and resolve within 10 days. However, 2%-10% of patients develop a secondary bacterial infection, most commonly with Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis. Diagnosis of ABRS is typically made when >1 of the following is present: Persistent symptoms/signs of rhinosinusitis for >10 days Severe symptoms, high fever (>39 C [102.2 F]), purulent nasal discharge, and/or facial pain for >3 consecutive days "Double sickening" - initial improvement of viral upper respiratory symptoms for 5-6 days, followed by clinical deterioration (eg, worsened fever, headache, nasal discharge) Patients with ABRS are usually treated with 5-7 days of oral amoxicillin-clavulanate to reduce symptom duration. Intranasal saline irrigation and analgesics are also often recommended (Choice A) Patients with poorly controlled diabetes mellitus (particularly with ketoacidosis) are at risk for rhino-orbital mucormycosis, which is treated with intravenous fungal medications. Manifestations typically progress rapidly and include fever, nasal necrosis, facial swelling, sinusitis, and headache. This patient on an insulin pump likely has well-controlled diabetes mellitus; she would be at low risk for mucormycosis. (Choice B) Allergic rhinitis can be treated with pollen avoidance and intranasal glucocorticoids. Manifestations typically include paroxysms of sneezing, rhinorrhea, and nasal itching. Fever and purulent nasal secretions would be atypical. (Choice C) Patients with evidence of bacterial infection that has spread beyond the sinuses and into the central nervous system, orbit, or surrounding tissue are considered to have complicated sinusitis and require laboratory testing and imaging. This patient's symptoms are localized to the sinuses and nasal cavity; empiric antibiotics are sufficient. (Choice E) Patients with viral rhinosinusitis can be reassured and advised to undergo symptomatic treatment (eg, analgesics). This patient has several features of ABRS, including persistent symptoms and "double sickening"; she requires antibiotics. Educational objective: Acute rhinosinusitis is most commonly due to viral pathogens and usually resolves within 10 days. Patients with persistent symptoms >10 days, severe symptoms, or deterioration after several days of improvement often have acute bacterial rhinosinusitis, which is usually treated empirically with 5-7 days of oral amoxicillin-clavulanate. References: Clinical practice guideline: adult sinusitis. (http://www.ncbi.nlm.nih.gov/pubmed/17761281) IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. (http://www.ncbi.nlm.nih.gov/pubmed/22438350)

A 22-Year-Old Woman Comes to the Office in April Due