A 28 year old female comes to your independent pharmacy for consultation. She is complaining of sinus drainage, on and off productive cough, pain, and headaches for the past two weeks. She felt like her symptoms were improving but two days ago she felt worse with increasing maxillary pain and fever of 101F. Her past medical history is significant only for CKD Stage 3 for which she takes lisinopril 20mg daily. She asks your professional opinion on appropriate treatment for her condition.
What is the most appropriate recommendation for our patient regarding management?
A. Oxymetazoline 0.05% 2 sprays each nostril BID for 5 days
B. Ibuprofen 400mg by mouth three times daily as needed for 5 days
C. Cetirizine 10mg plus pseudoephedrine 120mg BID for 5 days
D. Refer to physician for evaluation and management
Answer with rationale:
The correct answer is D. Most cases of acute sinusitis have a viral etiology where symptom management is the core treatment strategy along with possible nasal rinses. This patient however has had symptoms for > 10 days and initially improved followed by clinical worsening. These details point toward a possible bacterial etiology. Therefore the patient should be evaluated for potential antibiotic therapy. Answer A however is not correct regardless as Afrin should only be given for 3 days or less to limit rhinitis medicamentosa, which is severe rebound congestion. Answer B would not be appropriate as this patient has chronic kidney disease where NSAID therapy would be not recommended. Answer C could be used in conjunction with antibiotic therapy but data is conflicting on ultimate benefit and ultimately an evaluation is needed for definitive therapy.
Questions regarding medical referral are part of the exam. This can be found in NAPLEX Competency Statement 1.1.6 : Obtain, interpret, assess, and/or evaluate patient's need for medical referral.
More information can be found in our NAPLEX 3rd Edition Chapter on Upper Respiratory Tract Infections: Upper Respiratory Tract Infections