Given these changes from the original case, what is your diagnosis?
What is your diagnostic explanation?
As compared to the long case, this patient is a 43 y/o female who presents to urgent care saying: “I woke up this morning with a fever and my face really hurts.” She clearly appears mildly sick on general appearance, but is in no acute distress. She is holding a box of tissues and frequently blows her nose.
HPI: Patient notes that she awoke this morning feeling feverish and having facial pain. She describes the pain as a 6/10, sharp pain that is in her nasal/paranasal region. She also states that the pain is accompanied by nasal stuffiness and a pressure feeling as if “someone is pushing down on my face.” She states that nothing seems to make this pain any better, but touching her cheeks and bending her head down seem to make it worse. Her temperature was 99.6 when she took it this morning. Patient states that for the past week and half she had been experiencing flu-like symptoms (rhinorrhea, malaise, sneezing), but that for the past 2 days she started to feel “semi-decent.”
PM: Allergic to Sulfa drugs, results in hives
SH: No current or prior tobacco use; No current or prior alcohol use
FM: Non-contributory
ROS: General- No recent weight changes.
HEENT: No recent visual changes, dysphagia, or ear pain. Reports that rhinorrhea has worsened and that drainage is a dark yellow color. Drainage was clear previously.
Respiratory: Mild cough that is occasionally productive of yellow sputum. No shortness of breath or pleuritic pain.
Musculoskeletal: Reports that she feels achy all over.
PE:
VS – Height 5’4’’, Weight 130lbs, BMI 22.3, HR 80, BP 122/88, RR 12, Temperature 100.3
HEENT – Normocephalic, atraumatic, PERRLA, extraocular movements intact. Both tympanic membranes are able to be visualized and are unremarkable. Skin overlying maxillary sinuses show mild erythema and the maxillary sinuses are tender to palpation. Frontal sinuses are non-tender bilaterally. Nasopharynx shows erythematous turbinates bilaterally with a fair amount of purulent discharge present in each nostril. Examination of the pharynx shows moist, pink mucosa with no exudate.
Neck – Bilateral, tender lymphadenopathy of the submandibular lymph nodes.
Cardiac – Normal S1, S2 present with no rubs, gallops, or murmurs.
Lungs – Normal vesicular breath sounds in all posterior, anterior, and lateral lung fields.
Labs:
- CBC –
Hemoglobin 13.0 mg/dl
Hct- 39%
RBCs- 4.9 million/mcl
WBCs- 15.2 million/mcl
Neutrophils- 88%
Monocytes- 6%
Lymphocytes -6% - Nasal Discharge culture – positive for Strep. pneumoniae