Diagnosis
Differential Diagnoses
- 1- Pain in the throat (R07.0)
- 2- Acute nasopharyngitis (J00)
- 3- Acute pharyngitis, unspecified (J02.9)
Diagnosis
- Acute maxillary sinusitis, unspecified (J01.00)
- Acute upper respiratory infection, unspecified (J06.9)
Plan/Therapeutics
- Plan:
- Further testing: Tests for determining bacterial sensitivity and radiography are possible if there are no positive effects of the prescribed treatment. Thus, “radiological tests, such as plain X-ray and computed tomography, may aid the diagnosis” (Baker & Barton, 2013, p. 24). Additional tests, including CRP and ESR, can be proposed.
- Medication: Augmentin (875 mg-125 mg tablet by mouth twice a day) is effective to cope with acute maxillary sinusitis in adults because amoxicillin/clavulanate is used as the first-line therapy for treating different types of sinusitis (Ahovuo-Saloranta et al., 2014). Side effects of Augmentin are nausea, vomiting, diarrhea, skin itching, and these adverse effects are addressed with changing doses. Tamiflu (75 mg capsule by mouth twice a day) is recommended to be used for treating upper respiratory infections and nasopharyngitis as “the neuraminidase inhibitor” to cope with fever, cough, and sneezing (Baker & Barton, 2013, p. 19). The adverse effects of Tamiflu include diarrhea, headache, dizziness, eye redness, and insomnia. To address these symptoms, it is possible to change the medication.
- Education: The patient will be educated to take medications according to the plan, control her body temperature, pay attention to possible adverse effects, and report them to the doctor.
- Non-medication treatments: The patient should be recommended to drink a lot of water and different hot fluids. The patient should adhere to bed rest and avoid feeling cold. A follow-up visit to the PCP doctor is planned in 1-2 days to evaluate the outcomes and receive the ENT doctor’s consultation.
Evaluation of patient encounter
The patient is diagnosed with acute maxillary sinusitis, and the purpose of prescribed antibiotics “is to decrease symptoms and restore the normal function of the sinuses, to prevent complications and the development of chronic sinusitis” (Ahovuo-Saloranta et al., 2014, p. 3). Additionally, Tamiflu is prescribed because “acute bacterial maxillary sinusitis is often preceded by an acute viral upper respiratory tract infection” (Ahovuo-Saloranta et al., 2014, p. 3). The proposed care plan is aimed at relieving symptoms and coping with the bacteria that caused sinusitis.
References
Ahovuo-Saloranta, A., Rautakorpi, U. M., Borisenko, O. V., Liira, H., Williams, J. W., & Mäkelä, M. (2014). Antibiotics for acute maxillary sinusitis in adults. Cochrane Database of Systematic Reviews, 2(11), 3-34.
Baker, I., & Barton, E. (2013). URTIs: Recommended diagnosis and treatment in general practice. Prescriber, 24(19), 16-28.