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A 36-year-old female presents with a 5-day history of clear nasal discharge, nasal congestion, and frontal headaches associated with nonproductive cough. There is no reported fever. On previous similar episodes the patient noted improvement with antibiotics. She has seasonal allergies, and uses loratidine as needed. Vital signs are normal. There is mild bilateral suborbital ridge tenderness present on examination. The nares are patent with a clear mucoid discharge; there is no pharyngeal erythema or exudates, and lungs are clear to auscultation.

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1. What is the most appropriate next step?

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Answer

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  1. The patient most likely has acute rhinosinusitis and, thus, symptomatic treatment is recommended. Symptomatic treatments with systemic or local nasal decongestants, saline nasal washes, and NSAIDs have been shown to have some benefit in alleviating symptoms. Antibiotics are unlikely to be effective in most patients who have acute rhinosinusitis as demonstrated by a randomized trial and metanalysis showing no difference in the duration of symptoms between those who were treated with antibiotics and those who were not. Imaging studies such as CT scans and plain films of sinuses with or with out aspiration of sinus/nasal discharge for gram stain and culture are only indicated in cases where a patient is predisposed to atypical infections such as fungal or pseudomonal infections, seen mostly in the immunocompromised. It is recommended to not give antibiotics or perform imaging studies in patients with acute rhinosinusitis.

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Nonspecific Infections of the Upper Respiratory Tract

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The common cold, infective rhinitis or nasopharyngitis, encompasses the nonspecific and often uncomplicated upper respiratory tract infections (URIs) without prominent localizing symptoms. They are the major cause of ambulatory visits in the United States, leading to significant direct and indirect costs—accounting for 36 million physician visits per year at an estimated cost of $40 billion annually. They also lead to productivity losses related to lost workdays for adults who get sick and to those whose children get sick. There appears to be a seasonal variation in the United States with increased prevalence from September to March.

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Etiology

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Viruses are the major pathogens causing URIs. The most common are the rhinoviruses (52%), followed by coronaviruses, influenza A and B viruses, parainfluenza, and adenoviruses. Respiratory syncytial virus (RSV) is a well-recognized cause of URIs in the pediatric population that should also be recognized in the elderly and immunocompromised. Bacterial pathogens are uncommon but those identified are Chlamydia pneumoniae, Haemophilus influenzae, Streptococcus pneumoniae, and Mycoplasma pneumoniae. Secondary bacterial infections may complicate viral URIs in 0.05% to 2% of cases and may be manifested as rhinosinusitis, otitis media, or pharyngitis. These often present with recurrent symptoms after an initial improvement, particularly in patients at the extreme of ages and those who are chronically ill.

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The mechanism of transmission of viruses and bacteria is via contact with ...

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