A 46-year-old man presents with 12 days of nasal congestion, cough, and facial pressure. His symptoms initially improved around day 6, but 3 days later he developed increasing unilateral maxillary pain, worsening nasal discharge, and recurrent congestion. He has no significant medical history, medication allergies, or recent antibiotic use.
His vital signs are temperature, 100.2°F; heart rate, 86 beats/min; blood pressure, 126/78 mm Hg; respiratory rate, 16 breaths/min; and SpO₂, 98% on room air. Examination shows nasal congestion and mild right maxillary tenderness without facial swelling, orbital abnormalities, or neurologic findings.
Which finding most strongly supports a diagnosis of acute bacterial rhinosinusitis in this patient?
- Green nasal discharge
- Facial tenderness
- Temperature >100˚F
- Worsening after initial improvement
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Correct answer: d. Worsening after initial improvement.
Rationale: The pattern of improvement followed by recurrent or worsening symptoms (“double worsening”) increases the likelihood of acute bacterial rhinosinusitis. Because this patient is otherwise healthy and has no evidence of complicated disease, management may include shared decision making regarding watchful waiting, a safety-net antibiotic prescription, and symptomatic treatment.
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Tracey Davidoff, MD, FACP, FCUCM, has practiced Urgent Care Medicine for more than 15 years. She is Board Certified in Internal Medicine. Dr. Davidoff is a member of the Board of Directors of the Urgent Care Association and serves as Co-Editor-in-Chief of the College of Urgent Care Medicine’s “Urgent Caring” publication. She is also the Vice President of the Southeast Regional Urgent Care Association and a member of the editorial board of the Journal of Urgent Care Medicine. At EB Medicine, Dr Davidoff is Editor-In-Chief of Evidence-Based Urgent Care, and co-host of the Urgentology podcast.
