Hello Everyone - Today I will be presenting on Mrs S a 66 year old presenting mainly with

pressure headaches, nasal congestion and Facial tenderness.

Now Mrs S had been previously been diagnosed with acute sinusitis and was given a 10 day
course of antibiotics.
Slide 2 :
4 weeks later at her follow up appointment, we are back where we started and she reported
that there hasn't been any major improvement since taking the medication.

She is frustrated from the constant nasal congestion and is worried that this could be a
permanent situation as shes been suffering with the same symptoms for a year at this point.
Slide 3:
I began the consultant by
 Taking a detailed history of her symptoms -
 My approached to her headache symptoms was the same as that to pain anywhere in
the body- by implementing the Socrates pain assessment tool.
 Classified the severity of her overall symptoms using the Visual Analogue Scale
 Inquired about any allergies - any family history of atopy or any drug induced allergies
 Made sure to cover the RED FLAGS symptoms such as
o Any visual complaints
o Any periorbital oedema - Puffy eyes
o Unilateral bleeding
o Persistent or unexplained nose bleeds

Slide 4: Presenting illness

She complains that she is still experiencing her headaches at least 5 times a week

Describes the headaches as Frontal occipital, not relieved by pain medication and gradual get
worse during the day. On a scale of 1 to 10 she scores her pain at a 5 to 6 during the morning
and a 8/ 9 in the evening

On the Visual analog Scale she classifies her symptoms at a 7 which deems them moderate

She is also experiencing facial tenderness around the maxillary sinus and it radiates up
towards the frontal sinus

Reports that she is still experiencing nasal congestion and yellow mucus discharge, unilateral
runny nose, and post nasal discharge

On further questioning --> she denies any difficulty in smelling, itchy or watery eyes ( which
show signs of rhinitis) fevers and chills, tooth pain and any changes in vision.

Slide 5& 6 : PAST MEDICAL HISTORY and DX and SX --> Read from Slide

Slide 7 : Examination
On inspection and observation -
 Mrs S was well groomed and dressed appropriate for her age
 She was awake and well oriented
  Her voice was not horse but the patients she has noticed a change in her voice
 There were no scars and masses on her neck

Her vitals were all normal with a BP of 130/85 , Pulse of 70 and a Temp of 36

I performed a respiratory examination which was normal and unremarkable

On palpation of her face - she had Facial tenderness over the maxillary and frontal
areas

ENT EXAM
 Nasal exam - where we examined the nasal canal for any polyps which we did not find
 We did an Ear canal exam - and found she had a normal tympanic membrane therefore
it was otherwise unremarkable

With the information I collated in the previous slides --> I was able to rule out some of the
differential diagnosis such as
Acute sinusitis - based on the duration of her symptoms
Allergic rhinitis - based on the fact that she isn't sneezing experiencing any ocular
irritation and itching

I was also able to rule out Migraine as she was not experiencing some key symptoms such as
photophobia, aura (visual changes)

Therefore the Mrs S was diagnosed with Chronic sinusitis - which is essentially a
complication of Acute sinusitis

Chronic sinusitis is an inflammatory disorder of the paranasal sinuses and the lining of the
nasal passages.
It is sub categorised by the presence of absence of nasal polyps
And so in Mrs S case she has chronic sinusitis without nasal polps

Its is characterised by the following symptoms which were present in the history taken from
the patient --> Read

How patient was managed =

She was offered read
And was told to come back after 4 weeks for a review

Nice Guidelines -Read from Slide

How would you know when to refer--> Read from slide

Prednisolone - synthetic glucocorticoids - same effect as cortisol -

Peptic ulceration with use with nsaids
Enhance or reduce warfarin effect
Antagonise hypoglyceamic effect of antidiabetics
 Fluticasone is a synthetic glucocorticoid which is used to treat nasal symptoms.[1][2][3][4][5] Both
the furoate and propanoate esters, fluticasone furoate and fluticasone propionate, are also
used as topical anti-inflammatories[6] and inhaled corticosteroids, and are used much more
commonly in comparison
 sores in the nose that won't heal,
 headache,
 throat infection,
 sore throat,
 nasal irritation,
 sinus pain,
 sneezing,
 cough,
 nausea,