for NU 664B Week 1 Discussion 1: Telehealth/Transgender

for NU 664B Week 1 Discussion 1: Telehealth/Transgender

The differential diagnosis for this patient would include acute viral rhinosinusitis, acute bacterial rhinosinusitis, allergic rhinitis, hormonal related rhinitis, nasal polyps, foreign body, septal deviation, or covid-19.  Acute viral rhinosinusitis, acute bacterial rhinosinusitis, covid-19, rhinitis medicamentosa, and allergic rhinitis all need to be considered because these are the common causes of inflammation of the nasal and sinus mucosa which lead to the presentation of the symptoms the patient is experiencing including rhinitis and sinus pressure (Goldsobel et al., 2019). The other consideration with this particular patient would be rhinitis due to the fact that the patient is on hormonal therapy because fluctuations in estrogen levels may cause rhinitis (Dunphy et al.,2019). Nasal polyps, foreign bodies, or septal deviation can lead to a feeling of pressure or blockage (Dunphy,2019).  Acute viral rhinosinusitis would be at the top of the list of differentials because 95 percent of acute rhinosinusitis cases are caused by viruses that are responsible for uncomplicated upper respiratory infections (Dunphy et al.,2019). According to Dunphy (2019), ruling in the diagnosis of rhinosinusitis is based off a history of upper respiratory symptoms for at least 7 days with the presence of two or more of the following: headache, sinus or facial pain, lack of response to decongestants, and nasal secretions that are colored. The differentiation between viral sinusitis and the possibility that the condition is complicated by bacterial rhinosinusitis is made based on presentation of symptom severity in addition to length of duration of symptoms. When the duration of symptoms has been over a week to ten days the chances of bacterial sinusitis are more likely (Dunphy, 2019). The only definitive way of identifying the causative organism would be a sinus aspiration however, this is not commonly done in practice due to the invasive nature of the procedure (Dunphy,2019). At this time covid-19 testing is readily availably so I would use a covid-19 rapid antigen test to help rule in or out that diagnosis.  A physical examination would help to rule out nasal polyps, septal deviation, or foreign body contributing to symptoms (Dunphy,2019). Physical exam would also be useful in ruling in or out allergic rhinitis. Typically, in allergic rhinitis the nasal mucosa is pale and edematous or may have a bluish hue and the conjunctiva of the eyes may also be inflamed. In the history the patient may report itching, frequent sneezing, or a cyclic pattern to symptoms.  The patient history and hormone screening labs would help rule in or out the possibility of rhinitis caused by hormonal fluctuations (Dunphy,2019). Rhinitis medicamentosa would be ruled out by taking a careful history that involves inquiring about the use of any over the counter or prescription topical vasoconstrictive medications (Dunphy,2019). The patient in this case has not used any over the counter or prescription medications which rules out the diagnosis of rhinitis medicamentosa.

After assessing this patient based on the history provided including the duration and severity of symptoms, I would treat this patient for viral rhinosunisitis. I would recommend that the patient use saline nasal spray twice a day to improve sinus drainage (Dunphy, 2019). The patient should also increase fluid intake and rest. Using heated mist from a hot shower or bath for steam inhalations can help liquefy secretions which will improve nasal and sinus pain. I would also recommend the use of a neti pot for nasal irrigation.  For the nasal congestion I would recommend that the patient use afrin one to two sprays in each nostril three time a day as needed to be used for 3-4 days only (Dunphy,2019). Due to this patient’s history of elevated blood pressure readings, I would prefer to try a nasal spray prior to Sudafed due to the fact that Sudafed can elevate blood pressure. I would advise the patient to use guaifenesin 400 mg every 4 hours as needed because this help will to facilitate drainage of sinus secretions by liquefying them (Dunphy, 2019). For this patient I would educate that the majority of cases of rhinosinusitis are caused by viral infection and that only about 0.5% of all upper respiratory infections are complicated by bacterial infection therefore, there is no medical benefit to antibiotics in this case and there are risks involved with taking unnecessary antibiotics. I would instruct the patient to notify the office if symptoms failed to improve by 7-10 days or if symptoms worsen. I would instruct the patient to also contact the office with worsening facial pain, fever, or if purulent nasal discharge occurred (Dunphy, 2019). I would discuss with the patient that viruses are contagious so I would recommend avoiding contact with others to reduce the spread of the illness (Dunphy,2019). I would recommend that the patient should follow up with the specialist that is providing hormone therapy as levels should be checked. I would not recommend labs or imaging at this time however, if symptoms continued for more than 10 days and were worsened, I would consider antibiotic therapy. Referral to an ENT specialist would be indicated if symptoms still failed to resolve with antibiotic therapy (Dunphy,2019).

In addressing health maintenance, the patient reported using recreational marijuana and I would encourage the patient to refrain from smoking as the inhaled smoke can be an irritant and exacerbate the symptoms that are being reported and lead to developing nasal and sinus symptoms more frequently (Dunphy, 2019). I would also take this opportunity to review the patient’s immunizations and if covid-19 vaccinations and/ or influenza vaccinations were not up to date I would recommend receiving them when symptoms resolve to prevent development of illness in the future.

In addressing the social determinants of health, I would consider the fact that transgender women may be more prone to experience homelessness, unemployment, and poverty (Garcia & Crosby, 2020). Environmental factors can predispose patients to frequent sinus and nasal problems due to contact with allergens and irritants (Dunphy,2019). I would ask about any problems with the home environment and refer the patient to appropriate resources to assist with housing problems if necessary.

References

Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2019). Primary Care (5th

ed.). F. A. Davis Company.

Garcia, J., & Crosby, R. A. (2020). Social Determinants of discrimination and access to health

care among transgender women in Oregon. Transgender Health, 5(4), 225–233.

https://doi.org/10.1089/trgh.2019.0090

Goldsobel, A. B., Prabhakar, N., & Gurfein, B. T. (2019). Prospective trial examining safety and

efficacy of microcurrent stimulation for the treatment of sinus pain and congestion. Bioelectronic Medicine, 5(1). https://doi.org/10.1186/s42234-019-0035-x