A 28-year-old man comes to the office asking for antibiotics to treat a "sinus infection." He reports recurrent episodes of nasal congestion, rhinorrhea, and dry cough. The patient has used over-the-counter allergy medicines with some relief but continues to feel uncomfortable and has difficulty concentrating at work. He does not have shortness of breath, chest pain, or ocular symptoms. The patient has no prior history of allergies or asthma but had eczema during childhood. He does not use tobacco, alcohol, or illicit drugs. His temperature is 37 C (98.6 F), blood pressure is 120/78 mm Hg, and pulse is 76/min. Physical examination shows a transverse nasal crease, swollen and pale nasal turbinates, and a clear nasal discharge. There is no maxillary sinus tenderness. The posterior pharyngeal wall has a "cobblestone" appearance. Breath sounds are normal with no added sounds. Which of the following is the most effective therapy for this patient's condition?

Question

A 28-year-old man comes to the office asking for antibiotics to treat a "sinus infection."  He reports recurrent episodes of nasal congestion, rhinorrhea, and dry cough.  The patient has used over-the-counter allergy medicines with some relief but continues to feel uncomfortable and has difficulty concentrating at work.  He does not have shortness of breath, chest pain, or ocular symptoms.  The patient has no prior history of allergies or asthma but had eczema during childhood.  He does not use tobacco, alcohol, or illicit drugs.  His temperature is 37 C (98.6 F), blood pressure is 120/78 mm Hg, and pulse is 76/min.  Physical examination shows a transverse nasal crease, swollen and pale nasal turbinates, and a clear nasal discharge.  There is no maxillary sinus tenderness.  The posterior pharyngeal wall has a "cobblestone" appearance.  Breath sounds are normal with no added sounds.  Which of the following is the most effective therapy for this patient's condition?

Quizplus · Accepted Answer

11ec25c8_d21d_86bc_bc81_fd31965fda35_MD0003_00 This patient has typical features of allergic rhinitis including nasal congestion, clear rhinorrhea, and pale, edematous nasal mucosa. Patients may also have nasal creases, pharyngeal cobblestoning, conjunctival edema, or thick, green nasal discharge. During peak allergy seasons, patients can experience systemic (eg, fever) or neuropsychiatric (eg, fatigue, irritability) symptoms. Atopic disorders (eg, allergic rhinitis, "hay fever," asthma, eczema) frequently cluster in families, but individual patients usually experience only a subset of these manifestations. nasal creases Allergen avoidance can mitigate the symptoms of allergic rhinitis but is not always possible, and even low-level exposure can trigger bothersome symptoms. Glucocorticoid nasal sprays (eg, fluticasone, mometasone) are the most effective single agents. An initial response can be seen within several hours of administration, but maximal benefits may require continuous treatment for several days or weeks. Nonsedating oral antihistamines (eg, loratadine, cetirizine), antihistamine (eg, azelastine) or cromolyn nasal sprays, and leukotriene modifiers (eg, montelukast) are less effective but can be considered based on the patient's symptoms and drug tolerances (Choice E). (Choice A) Inhaled beta agonists are indicated for patients with asthma. Patients with wheezing should be evaluated for possible asthma, but a dry cough alone is a nonspecific symptom. (Choice B) Nasal decongestant sprays can reduce mucosal edema but are less effective overall than glucocorticoids and can cause rebound congestion (rhinitis medicamentosa). (Choice D) This patient has no fever or sinus tenderness to suggest bacterial sinusitis. Educational objective: Glucocorticoid nasal sprays are the most effective single agent for allergic rhinitis, although maximal benefits may require continuous treatment for several days or weeks. Oral antihistamines, antihistamine or cromolyn nasal sprays, and leukotriene modifiers can be considered based on the patient's symptoms and drug tolerances. References: Mechanisms and clinical implications of glucocorticosteroids in the treatment of allergic rhinitis. (http://www.ncbi.nlm.nih.gov/pubmed/19737138)

A 28-Year-Old Man Comes to the Office Asking for Antibiotics