18 Oct Sandy is a 64-year-old patient with a 10-year history of recurrent sinusitis. She presents to your primary care clinic today complaining of “head congestion.” She also reports that she had a “cold” last week with symptoms of cough and “runny nose.”

Select one of the following case studies to address. In the subject line of your post, please identify which prompt you are responding to, for example,  #2 Carl, type 2 diabetes.

Discuss what questions you would ask the patient, what physical exam elements you would include, what further testing you would want to have performed, differential and working diagnosis, treatment plan, including inclusion of complementary and OTC therapy, referrals and other team members needed to complete patient care.

In your peer replies, please reply to at least one peer who chose a different case study.

Case Studies

1. Sandy is a 64-year-old patient with a 10-year history of recurrent sinusitis. She presents to your primary care clinic today complaining of “head congestion.” She also reports that she had a “cold” last week with symptoms of cough and “runny nose.” Two days ago, she developed a headache that was “worse” when bending over but improved with Tylenol. She describes the headache as a “3 out of 10” and says it is primarily a “frontal headache.” She also reports that her nasal congestion has become worse. She has been blowing her nose even more, and the discharge from her nose has become thicker, with a yellow-green color. She has been taking pseudoephedrine for the past 48 hours with little relief of her nasal congestion. She denies tooth pain or pain on chewing. She has no past history of seasonal allergies, although she was treated for sinusitis 6 months ago in your clinic as well as approximately one year ago.

The remainder of her medical history is essentially negative. Her temperature taken at the clinic is 99.6°F.  On physical examination, she has tenderness to palpation in the frontal area and no maxillary tenderness, and nasal mucosa is erythematous as is her pharynx. Her submaxillary nodes are enlarged bilaterally, but there is no cervical lymphadenopathy. Her lungs are clear to auscultation. Her heart has a regular rate and rhythm and is negative for murmurs, gallops, and rubs. Her vital signs are:

Blood pressure:128/88; Pulse: 78 and regular; Respiratory rate: 20 p/min, non-labored.

2. Maeve, a 62-year-old widow, presents with an elevated papule that has a pearly appearance with a little crusting on her back above her bra strap. It’s about 8 mm and brown. She states that she didn’t even know it was there until she was wearing a bathing suit recently, and someone at the pool suggested that she have it checked out by a doctor. Since she’s now aware of it, she states that it itches.

3. Callie is a 32-year-old female with complaints of a hoarse voice for the past three days, painful swallowing without drooling, fever with a Tmax of a 103 yesterday with chills, and occasional body aches. She presents to the clinic with a temperature of 99, while other vital signs are within normal limits. Cervical lymph nodes are mildly enlarged and tender. Both tympanic membranes (TM) are full and erythematous without bulging or drainage and no facial pain. Pharynx is erythematous and swollen without exudate. She has no other complaints and no significant past history; she has no sick contacts.

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