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Continued information gathering

Lauren’s symptoms appear to be typical of an upper respiratory tract infection with nasal congestion as the predominant symptom. At this point it would be useful to know what, if any, other symptoms she has experienced over the past 10 days, as well as details about her current nasal and facial symptoms. 

Lauren tells you that she started off with a sore throat which lasted a few days but was then replaced by a blocked-up nose, which is now making her face ache. When blowing her nose the discharge is yellowish-green. She says she was sneezing quite a bit at the start but that seems to have settled down. She has no cough at present and does not report a temperature.

Lauren’s symptoms seem to suggest she has a common cold. Typical presentation is sudden sore throat that rapidly resolves, followed by profuse nasal discharge, congestion and sneezing. Cough, headache, fever and general malaise may be present. However, her symptoms seem to have lasted longer than normal – cold symptoms usually peak after two to three days and in adults last about one week. 

Allergic rhinitis also seems unlikely as the discharge is mucopurulent, sneezing is not prominent and she has facial pain – all atypical findings. To further rule out allergic rhinitis, one would expect a negative history of atopy. Lauren confirms that this is the case. 

Problem refinement

Duration and now presence of facial pain point toward Lauren developing sinusitis, most likely of viral origin. However, a number of conditions cause facial pain but her symptoms of mucopurulent discharge, facial tenderness and location of pain do not suggest any of these. 

In sinusitis, many patients experience local tenderness and pain when bending over or lying down. Lauren says her cheek area is sore to the touch. This supports a differential diagnosis of a common cold that has developed into sinusitis.

Review/red flag

You confirm with her that nasal blockage affects both nostrils, allowing you to rule out conditions where unilateral nasal blockage or discharge are prominent; for example deviated nasal septum, turbinate hypertrophy and malignancy.

Management and safety netting

NICE guidance on sinusitis (NG79) found none or very limited evidence through randomised controlled trials for the effectiveness of simple analgesia, saline nose drops or decongestants. However, based on clinical experience, NICE recommended it was reasonable to use simple analgesia to manage pain, and nasal saline or nasal decongestants for congestion. 

The use of oral decongestants and anti-histamines should not be recommended. After checking Lauren’s medical history you decide to recommend paracetamol to help with the facial pain. If symptoms worsen (e.g. she develops fever and severe local pain) or persist beyond two to three weeks, it is possible she might have developed bacterial sinusitis.