Case Study

Upper Respiratory Infection, Pharyngitis, Sinusitis, Otitis Media, and Otitis Externa 

Case Study 1:

Acute Maxillary Sinusitis 

Complaint 

Rve got a cold that will not go away./p>

History 

A 45-year-old male presents with a 2 week history of green nasal discharge and cough. He states that for the past 48 hours he has had a headache that worsens when he bends over. He reports that his kids all have ïlds!nd that his symptoms are lasting longer than theirs are. His history is notable for a 25 year history of smoking one pack per day of cigarettes, which he recently has been able to decrease to half a pack per day. He has no known drug allergies. He states that he did have a sinus infection 4 or 5 years ago that cleared with antibiotics. He is generally healthy. 

Assessment 

His vital signs are all within normal limits, except for an oral temperature of 100.6® 

His physical examination reveals the following: 

1. Tympanic membranes are translucent gray, nasal turbinates are beefy red and swollen, and throat is clear with some green postnasal drip noted. 

2. Patient complains of tenderness over his maxillary sinus area bilaterally. 

3. Lymph glands show no adenopathy. 

4. Heart has regular rhythm and rate, with no murmur. 

5. Lungs show clear breath sounds in all fields. 

Topics for Discussion:

1. What is the initial management plan for an adult with sinusitis? 

2. How would the plan change if the patient is allergic to penicillin?