Diagnostic Reasoning Case Study Facial Pain

Summary Case study
A young male with a 5-day history of facial pain, dental discomfort, blood-streaked nasal discharge, and morning headaches. These symptoms came four days after a one-week course of a mild headache, rhinorrhea, ear pressure, and sore throat. He has used Advil for the symptoms, but no improvement. He is a nonsmoker and has seasonal allergic rhinitis. On examination, he has erythematous and swollen nares, tender frontal and maxillary sinus, cobble-stoning of the pharynx, and grade 2 tonsillar enlargement.
	Differential 1 Acute viral rhinosinusitis	Differential 2 Acute pharyngitis	Differential 3 COVID-19
Epidemiology (short synopsis) for each	Affects about 12% of the US population; affects women more than men; common in patients aged between 40 and 60 years old; smoking, immune weakening, asthma, and allergies are documented risk factors. (Dhingra & Dhingra, 2021)	Commonly caused by viruses in about 25-45%. The bacterial type is most commonly caused by group A streptococcal infections. Occurs both in children and adults. Most cases of acute pharyngitis are seen in cold seasons. Annually, more than 12 million cases are diagnosed in the US with acute pharyngitis (Arnold & Nizet, 2018).	First detected in December 2019 when many people were admitted with serious pneumonia of unclear etiology. Since then, it has caused a pandemic with significant mortalities in all countries. It has no genetic, gender, or predilection, but moralities and other poor outcomes have been associated with racial and socioeconomic disparities (Aimrane et al., 2022)
Pertinent positives for each	Facial pain, mild headache, seasonal allergies, nasal discharge, dental discomfort, and recent history of the common cold.	Nasal symptoms (Bennett, 2022), cobblestone throat appearance, previous history of cold symptoms, and headache	Sore throat, cobblestone throat, headache, tiredness, acute course of the illness,
Pertinent negatives for each	Less than 10-day course, no fever, no worsening of symptoms severity, lack of purulent discharge (American Academy of Family Physicians, 2020)	No fever, no pharyngeal erythema, no cervical lymphadenopathy, no odynophagia, no peritonsillar exudates	No fever, no chest pain, no cough, no shortness of breath
Patho short summary for each	In more than 90% of the cases, AVRS follows a viral upper respiratory tract infection (Dhingra & Dhingra, 2021). The virus spreads into the sinus through the nasal cavity and reduces McCleary clearance in the sinuses, enhances mucosal permeability, and induces further inflammatory reactions leading to obstruction of thick secretions and mucosal edema presenting as tenderness, fullness, pressure, and headache	Several viruses that cause URTIs also cause acute pharyngitis. The bacterial type is caused by bacteria such as Group A streptococci (GAS) causes acute pharyngitis (CDC, 2022). Epithelial cellular response to these infections and cytotoxic effects of the viruses lead to mucosal erythema and edema. Sore throat and odynophagia can ensue. In bacterial cases, especially GAS, acute rheumatic fever, and acute kidney injury can result (Sykes et al., 2020).	A severe acute respiratory syndrome pandemic caused by a coronavirus (SARS-CoV-2). Spread through human-to-human routes, coronavirus enters human cells in the upper and lower respiratory tract and, through cytotoxic effects, causes an inflammatory response and cytokine productions that lead to breathing difficulties and other symptoms such as myalgia, sore throat, and other respiratory tract symptoms (Aimrane et al., 2022)

Assessment:

Diagnoses

Primary: acute viral rhinosinusitis
Secondary diagnoses: allergic rhinitis, migraine headache

Plan and Rationale

Rapid diagnostic antigen tests against streptococci to rule out streptococcal pharyngitis
Throat culture to identify causative organs and target antimicrobial treatment (Letourneau, 2018)

Pharmacologic treatment and Rationale:

Analgesic for pain NSAIDS (IBU) as needed for headaches
Intranasal steroids for symptomatic relief by preventing further inflammation of the sinuses and nasal mucosa, also for allergic rhinitis symptoms (fluticasone)
Continue baby aspirin
Antihistamine – explain (Zyrtec, Allegra, Xyzal)
Antibiotic therapy will be determined by the culture and antigen testing results
Augmentin 875 mg every 12 hours for 7 days – about $15 for every 2 tabs

Side effect of medications:

Augmentin most commonly causes headache, nausea, and vomiting
Antihistamines most commonly cause drowsiness and blurred vision
Intranasal steroids – dry nose, throat irritation, and nasal itchiness
Baby aspirin – nausea, vomiting, ringing in the ears, easy bruising, yellowing foe eyes
NSAIDS – headache, dizziness, nausea, and vomiting

Non-pharmacologic treatment:

Avoid allergic rhinitis triggers (such as) cat dander, house dust mites, pollen, and wood dust
Adequate water intake to prevent dehydrations
Humidifier to prevent drying of the mucosa and thickening of mucus

Follow up:

Follow up in 5 days to assess progress and evaluate culture results to rule out a bacterial rhinosinusitis if the symptoms worsen or persist (American Academy of Family Physicians, 2020)

Referrals:

Referral to ENT specialist if no improvement after 10 days or if any complications for further reevaluation and treatment. Complications such as periorbital cellulitis, abscess, or cavernous sinus thrombosis (Pradhan et al., 2018)
Referral to an immunologist for allergy testing

Referrals to interprofessional:

None
Referral to an ophthalmologist if orbital complications develop

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References

Aimrane, A., Laaradia, M. A., Sereno, D., Perrin, P., Draoui, A., Bougadir, B., Hadach, M., Zahir, M., Fdil, N., El Hiba, O., El Hidan, M. A., & Kahime, K. (2022). Insight into COVID-19’s epidemiology, pathology, and treatment. Heliyon, 8(1), e08799. https://doi.org/10.1016/j.heliyon.2022.e08799

American Academy of Family Physicians. (2020, July 6). Adult Sinusitis. Aafp.org. https://www.aafp.org/family-physician/patient-care/clinical-recommendations/all-clinical-recommendations/adult-sinusitis.html

Arnold, J. C., & Nizet, V. (2018). Pharyngitis. In Principles and Practice of Pediatric Infectious Diseases (pp. 202-208.e2). Elsevier.

Bennett, J. E. (2022). John E. Bennett. In Caserta Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases (Vol. 59, pp. 824–831). Elsevier – Health Sciences Division. https://www.clinicalkey.com/#!/content/book/3-s2.0-B9780323755702007086

CDC. (2022, June 27). Pharyngitis (strep throat). Cdc.gov. https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html

Dhingra, P. L., & Dhingra, S. (2021). Diseases of ear, nose & throat and head & neck surgery – E-book (8th ed.). Elsevier.

Letourneau, A. R. (2018). Antibiotics in otolaryngology: A practical approach. In Infections of the Ears, Nose, Throat, and Sinuses (pp. 1–14). Springer International Publishing.

Pradhan, P., Samal, D.-K., Preetam, C., & Parida, P.-K. (2018). Intraorbital and intracranial complications of acute rhinosinusitis: A rare case report. Iranian Journal of Otorhinolaryngology, 30(100), 301–304. https://www.ncbi.nlm.nih.gov/pubmed/30245985

Sykes, E. A., Wu, V., Beyea, M. M., Simpson, M. T. W., & Beyea, J. A. (2020). Pharyngitis: Approach to diagnosis and treatment. Canadian Family Physician Medecin de Famille Canadien, 66(4), 251–257. https://www.ncbi.nlm.nih.gov/pubmed/32273409