SCC 1

Done by Bakhytbek Zhalmagambetov

CC: Patient, 32 years-old male was admitted to Emergency department due to
Fever (up to 38.5C) for a week, nasal congestion, generalized weakness, diffuse
headache
HPI: at 22:00 pm patient came to ED with abovementioned complains for a
week. He took acetaminophen 3 tablets when fever, tylol hot 1 pack. Everyday in
the evening temperature was rising (38.5C). Currently comes because was not
getting well.
PMH: Parents deny any previous TB, HIV, Hepatitis A,B,C. Denies blood
transfusions. No operations.

Allergies: NO

FH: No DM type I or II in the family. Father suffers from high blood pressure.

SH: smokes 0.5 pack per day for 5 years. Considers himself a social drinker. Works
as an engineer in a construction company. Lives with his parents. Not married.
 ROS
• GENERAL: decrease in appetite, no mood changes, admits having a
weakness
• HEENT: complains for difficulty of breathing, headache, throat itchiness
• CARDIO: not significant
• Resp: not significant
• GI: not significant
• GU: not significant
• MUSCULOSKELETAL: not significant
• Neuro: not significant
• Skin: not significant
 PE
• Vitals : BP-110/80, HR-80, RR-18
• General – in good mood, cooperative, normostenic
• HEENT – soft palate redness, no sputum. Difficulty breathing from both nares
• Cardiovascular – normal S1 and S2, no murmurs, no carotid bruits
• Lungs – weakened lung sounds, normal vocal fremitus, no use of accessory
muscles, expiratory wheezes on right lower lobe. CVT- negative
• Skin - No rashes, no ulcers
• Abdomen - Normal bowel sounds, abdomen soft and non-tender, not palpable
spleen, or liver
• Muscular/ Skeletal - 5/5 strength, normal range of motion, no swollen or
erythematous joints.
• Neurological – Alert and oriented x 3, CN 2-12 grossly intact. Reflexes +2
everywhere, Romberg negative, finger-to-nose test negative
 What do you want to take ?
CBC
CXR DDx
Sinus XR Sore throat
Culture ? Acute respiratory infection
Pneumonia
Sinusitis
 CBC (02/04/2019)
Leucocytes 11 x10*9/l (4-9)
Hemoglobin 147 g/l (130-160)
Erythrocytes 5.0x10*12/l (3.41-5,1)
PLT 227,00x10*9/l (180-320)
MCV 86.9
MCH 29.3
RDW-SD 41.8
RDW CV 13.5
Hematocrit 43.6
No differentials
CXR 02/04/2019
Sinus XR 02/04/2019
Definitions

Sinusitis can be broadly defined as inflammation of one or more of the

paranasal sinuses. Classically, sinusitis is characterized as the following:
Acute symptoms last less than 4 weeks
Subacute symptoms last 4 to 8 weeks
Chronic symptoms last longer than 8 weeks
Recurrent -three or more acute episodes a year
Frontal sinus

Frontal sinus
Posterior
Anterior ethmoid air
ethmoid air cells
cells
Superior
turbinate

Sphenoid sinus

Middle Meatus Middle

turbinate
Maxillary sinus
Inferior turbinate

Inferior meatus
Maxillary sinus

Patrick J. Lynch (Wikimedia Comomns)

11
 Sinusitis
Etiologic Organisms (and % incidence)
• Aerobic bacteria
• Strep. pneumoniae (30)
• Alpha & beta hemolytic Strep (5)
• Staph. aureus (5)
• Branhamella catarrhalis (15 to 20)
• Escherichia coli (5)
• Anaerobes (10 % acute, 66 % chronic)
• Peptostreptococcus, Propionobacterium,
Bacteroides, Fusobacterium
• Fungi (2 to 5)
• Viruses (5 to 10)

12
 Acute Sinusitis
Predisposing Conditions
• Local
• Upper Resp. infections
• Allergic rhinitis
• Nasal septal defects
• Nasal foreign bodies
• Dental infections
• Overuse of topical decongestants
• Nasal polyps or tumors
• Aspiration of infected water

13
 Acute Sinusitis
Usual Clinical Presentation
• Symptoms progress over 2 to 3 days
• Nasal congestion & discharge (usually thick &
colored, not clear)
• Localized pain +/- referred pain
• Tenderness or pressure sensation over sinuses
• Headache
• Cough due to postnasal drip
• Halitosis
• Malaise
14
 Referred pain

Frontal sinus

Ethmoidal sinus

Maxillary
sinus

Patrick J. Lynch (Wikimedia Comomns)

Paranasal sinuses and locations of referred pain (shaded orange)

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 Acute Sinusitis
Diagnostics XRay
• Plain films not as sensitive as CT
Radiographic signs of sinus pathology :
• Air fluid levels
• Partial or complete opacification
• Bony wall displacement
• 4 mm or more of mucosal wall thickening
• Advantages of CT :
• Visualizes ethmoid air cells
• Evaluates cause of opacified sinus
• Differentiates bony changes of
chronic inflammation from
osteomyelitis 16
Another diagnostic modality for sinusitis is nasal endoscopy

Direct visualization of the three

meatuses
Any pus ? Polyp ? Mass ?

Mani H. Zadeh, Wikimedia Commons 17