Question

• Please Write Succinct: Sinusitis
• Review of Systems: Associated symptoms and Risk Factors
• Findings on Focused Physical Exa
• Five Differential Diagnosis

See example below for question #1:

1. Sore Throat

ROS:

Associated symptoms: fever, redness or eye discomfort, sneezing, wheezing, cough, runny nose, postnasal drip, GERD like symptoms, fatigue, muscle ache, n/v, and diarrhea.

Risk Factors:

Smoking, new sexual partners, irritant exposure, medications, and chronic health problems.

Red flags:

drooling, unable to swallow, unable to lie down, restless, unable to stay still, and unable to talk.

PE findings:

Epiglottis- severe illness with signs of upper airway obstruction such as restlessness, stridor, difficulty breathing, drooling, inability to swallow and high fever signals epiglottis and requires immediate referral. Further examination with a tongue blade could trigger laryngospasms and lead to airway obstruction.

Peritonsillar retropharyngeal abscess- orthopnea, dyspnea, symmetrical swelling, abscess, trismus.

Viral pharyngitis: Erythema, edema of throat, tender posterior cervical nodes.

GAS: temp more than 101.5, exudate anterior cervical lymphadenopathy.

Mononucleosis: presence or absence of pharyngeal exudate, posterior cervical lymphadenopathy, splenomegaly.

Gonococcal pharyngitis: pharyngeal exudate bilateral cervical lymphadenopathy

Inflammation: sinus tenderness, pale or swollen pharynx, postnasal drainage visible, no fever or lymphadenopathy.

Aphthous Stomatitis: shallow ulcers, no vesicles; indurated papules that progress to 1 cm ulcers; ulcer has yellow membrane and red halo; no fever or nodes.

Herpes simplex Lesions: perioral lesions; lymph adenitis; vesicles on palate, pharynx gingiva.

Herpetic pharyngitis: vesicles, ulcers, or exudate of the oral and pharyngeal mucosa.

Candidiasis: curd like white plaques that bleed when scraped off.

Differential diagnosis:

Viral Pharyngitis, Streptococcal Pharyngitis, peritonsillar or retropharyngeal abscess, Mononucleosis, Epiglottis, gonococcal pharyngitis, Herpangina, Vincent angina, Aphthous stomatitis, HSV type 1, Candidiasis, GERD.

Answer 1

Sinusitis

ASSOCIATED SYMPTOMS

Nasal Discharge
Nasal Congestion
Facial Pressure/Pain
Fever
Pain in Upper Teeth
Bad Breath
Coughing
Sneezing
Headache
Associated with some syndromes
Kartagener syndrome-azoospermia/infertility /bronchiectasis /bronchitis
Young syndrome
Aspirin sensitivity
Nasal polyp

RISK FACTORS

SMOKING
INFECTIONS (common cold)
CERTAIN MEDICAL CONDITIONS
Individuals with HIV, cystic fibrosis, and diabetes are more at risk
ALLERGIES
Seasonal or acute flare ups can lead to sinusitis
NASAL PASSAGE ABNORMALITIES
A deviated nasal septum is a common cause

PHYSICAL EXAMINATION FINDINGS

On inspection, the Patient looks very toxic with raised
temperature & pulse, flushed/red
face,
On local examination
Anterior Rhinoscopy shows congestion and swelling of nasal mucosa, septum seen in contact with swollen turbinals,with thin or thick discharge,
Posterior Rhinoscopy shows generalized congestion and discharge sticking to the boundaries of posterior nares &
walls of naso-pharynx,

Palpation

Palpation elicits tenderness over
the affected sinus, with
comparison to the opposite side(healthy side ).

Also ,

Assess patients for changes in extraocular movements, and visual acuity to look for orbital complications.

Look for associated dental infection by checking the maxillary teeth for tenderness.

DIFFERENTIAL DIAGNOSIS

Nasopharyngitis / adenoiditis
Dental abscess Vestibulitis / furunculosis
Causes of chronic sinusitis like
Sarcoidosis
Tuberculosis
Rhinosporidiosis
Syphilis
Leprosy
Wegener's Granulomatosis
Midline (lethal) granuloma
Nasopharyngeal cancer.

Nasal septum deviation
Nasal foreign body Allergic rhinitis
Non-allergic rhinitis
Infectious rhinitis
Drug-induced rhinitis
Nasal polyps
Carcinoma of sinus
Cluster headache
Structural defects