Chronic sinusitis (ICD-10-CM Diagnosis Code J32) (ICD10 Data, 2017c, para. 1).
The patient reported inflammation of paranasal sinuses and nasal mucosa that has been lasting for 3 months. The presence of such inflammation for at least 12 weeks is a sign of chronic rhinitis (Shi et al., 2015). The other symptoms that point to this condition are the presence of nasal congestion and nasal discharge (Bachert et al., 2014). Sinusitis can develop due to infective and non-infective causes (Malaty, 2016).
Allergic rhinitis, unspecified (ICD-10-CM Diagnosis Code J30.9) (ICD10 Data, 2017a, para. 1).
Airflow obstruction is also a sign of allergic rhinitis; however, in many cases it is accompanied with such symptoms as sneezing, nasal discharge (mainly clear), and nasal pruritus (Wheatley & Togias, 2015). This is a likely diagnosis because allergic rhinitis is a very common condition in the United States, and it regularly affects at least one in six adults (Seidman et al., 2014).
Churg-Strauss syndrome (ICD-10-CM Diagnosis Code M30.1) (ICD10 Data, 2017d, para. 1).
The complicated breathing reported by the patient could also be a sign of the inflamed blood vessels in the upper respiratory tract – pulmonary eosinophilia – that is the major sign
of Churg-Strauss syndrome (Sharma, Agrawat, Julka, Varudkar, & Sharma, 2012).
Chronic rhinitis (ICD-10-CM Diagnosis Code J31.0) (ICD10 Data, 2017b, para. 1).
The patient reported nasal congestion but did not mention sneezing, swelling, and watering. The latter are the symptoms of allergic rhinitis, while nasal congestion without itching and the aforementioned signs indicates that the patient is affected by non-allergic chronic rhinitis whose symptoms often develop in older adults suffering from the condition (Schroer & Pien, 2012).
Chronic Rhinitis Plan
- Further testing: In-depth assessment of nose, eyes, ears, teeth; examination for inflamed tonsils and pharyngeal drip.
- Medication: Nasal steroids are the usual approach to the treatment of sinusitis (Malaty, 2016). Stop taking Afrin, replace with nasal spray for the minimization of symptoms and Azelastine.
- Education: Inform the patient about the importance of timely visits to a doctor in order to avoid the development of a chronic form of rhinitis.
- Non-medication treatments: Stop using hypertention medication currently taken – Afrin.
- Follow-up: follow-up with the physician in 7 days for a new assessment.
Chronic Sinusitis Plan
- Further testing: MRIs or X-ray of affected areas
- Medication: Amoxicillin for 2 weeks (250-500 mg) 3 times a day
- Education: Inform the patient about the harm of self-medication because not all medications for nasal congestion are equally effective.
- Non-medication treatment: Keep nose cavity clean using salty water
- Follow up: Follow-up with the physician in 7 days.
Allergic Rhinitis Plan
- Further testing: Allergy testing
- Medication: Zyrtec – every day (10mg), current hypertension treatment continued.
- Education: Inform the patient about the importance of avoiding allergens that can aggravate the condition further.
- Non-medication treatment: Staying away from allergens
- Follow-up: Follow-up with the physician in three days for an assessment
Churg-Strauss Syndrome Plan
- Further testing: Assessment using the list of Churg-Strauss syndrome criteria (at least 2 or 3 should match). X-ray and blood test.
- Medication: Prednisone (40-80 mg), lowering the dose gradually
- Education: Inform the patient about the purpose of the treatment and the condition
- Non-medication treatment: Keep nasal cavities clean using salty water.
- Follow-up: Follow-up with the physician in three and then once again in seven days.
The assessment of the patient went normally. The patient appeared and presented his chief complaint. He was inquired about his condition and then examined based on his complaints and the standard guideline for patient assessment. The information was sufficient for the formulation of differential and final diagnoses. Urinalysis and blood test were still pending; however, their completion could provide more important information.
Bachert, C., Pawankar, R., Zhang, L., Bunnag, C., Fokkens, W. J., Hamilos, D.,… Blaiss, M. (2014). ICON: Chronic rhinosinusitis. World Allergy Organization Journal, 7(25), 1-28.
ICD10 Data. (2017a). Web.
ICD10 Data. (2017b). Web.
ICD10 Data. (2017c). Web.
ICD10 Data. (2017d). Web.
Malaty, J. (2016). Medical management of chronic rhinosinusitis in adults. Sinusitis, 1, 76-88.
Schroer, L. C., & Pien, B. (2012). Nonallergic rhinitis: Common problem, chronic symptoms. Cleveland Clinic Journal of Medicine, 79(4), 285-293.
Seidman, M. D., Gurgel, R. K., Lin, S. Y., Schwartz, S. R., Baroody, F. M., Bonner, J. R.,… Nnacheta, L. C. (2014). Clinical practice guideline: Allergic rhinitis. Otolaryngology–Head and Neck Surgery, 152(1), S1–S43.
Sharma, A., Agrawat, J., Julka, A., Varudkar, H., & Sharma, P. (2012). Churg Strauss syndrome. Indian Journal of Allergy, Asthma and Immunology, 26(1), 11-13.
Shi, J. B., Fu, Q. L., Zhang, H., Cheng, L., Wang, Y. J., Zhu, D. D.,… Xu, G. (2015). Epidemiology of chronic rhinosinusitis: Results from a cross-sectional survey in seven Chinese cities. Allergy, 70, 533-539.
Wheatley, L. M., & Togias, A. (2015). Allergic rhinitis. The New England Journal of Medicine, 372(5), 456-463.