Youve made it halfway through the work week! Heres some midweek knowledge for you. The answer to Mondays Challenger: Answers Question 1: A. Allergic rhinitis, C. Epistaxis Answer Question 2: C. CT sinus cavities Rationale Included in the differential would be allergic rhinitis (AR) and epistaxis. He has symptoms consistent with allergic rhinitis (AR): inflammation of the nasal mucus membranes accompanied by edema and nasal stuffiness. The pale “boggy” turbinates and shiners are also red flags for AR. This condition could be the perfect stage for epistaxis to occur. The nasal membrane is filled with a rich vascular supply and when this nasal membrane lining is disturbed or irritated it can cause abnormal bleeding, hence, epistaxis. Epistaxis is a symptom. His symptoms are not suggestive of acute sinusitis because there is no report of postnasal drip or purulent nasal discharge. Additionally, the duration of these symptoms makes an alternate diagnosis, like chronic sinusitis, more likely. Advanced imaging studies should be part of the plan as well as referral to ENT. Chronic nasal congestion and headaches could be due to many different etiologies, some more likely than others---a tumor growing in his sinus cavity, allergic rhinitis, polyps, or chronic bacterial sinusitis. Since the nasal speculum was unable to be inserted, a major part of the exam and a good source of clinical information was unavailable. By visualizing the nasal passages, a clinician may identify tumors, polys, or other lesions. He reported finding a “sore” in the nasal passage, but this could not be verified and so should not be part of the differential. A dental abscess is also unlikely since the rest of the exam was unremarkable. The presence of “puffiness” over the right side of the face could possibly be suggestive of cellulitis, a dental abscess, a tumor, or other diagnoses. As the exam findings lacked symptoms consistent with a dental abscess, this diagnosis could be eliminated from the differential. Regarding the next course of action, advanced imaging studies should be obtained so a diagnosis can be made and appropriate treatment begun. He has been treated with antibiotics 4 times in the past 12 months. If he has had 4 actual sinus infections, it is very likely that something is impeding drainage (a tumor, a polyp, narrowed sinus tracts, etc.). A CBC and MRI of the head will likely be low yield exams. Arguably, a CBC could be ordered to check platelet count because of the epistaxis, but since the rest of the exam was unremarkable (no bruising, etc.), this seems less important than imaging studies. An exam that is more likely to introduce helpful information is CT of the sinuses. References Areaux, D. (2014). Epistaxis: Common and uncommon nosebleed. Clinical Advisor, 17(7), 28-43. Hollier, Amelie and Hensley, Rhonda. (2011). Clinical Guidelines in Primary Care: A Reference and Review Book. Lafayette, LA. Advanced Practice Education Association, Inc. Nasal Cavity and Paranasal Sinus Cancer: Symptoms and Signs. (n.d.). Retrieved September 16, 2014, from cancer.net/cancer-types/nasal-cavity-and-paranasal-sinus-cancer/symptoms-and-signs Nasal and paranasal tumors. (2013, July 8). Retrieved September 16, 2014, from mayoclinic.org/diseases-conditions/nasal-paranasal-tumors/basics/definition/CON-20036284
Posted on: Wed, 17 Sep 2014 17:56:32 +0000
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