Differential Diagnosis

• Single most likely diagnosis:
  • Acute rhinosinusitis (viral or bacterial): The patient's symptoms of yellow/green mucus, facial pressure, and productive cough with yellow/green phlegm are consistent with acute rhinosinusitis. The rapid progression of symptoms and the presence of purulent discharge suggest a possible bacterial component, but the initial improvement and subsequent recurrence of symptoms could also indicate a viral etiology or a secondary bacterial infection.
• Other Likely diagnoses:
  • Viral upper respiratory tract infection: The patient's symptoms of sore throat, cough, and nasal congestion could be indicative of a viral upper respiratory tract infection, which could have led to a secondary bacterial sinusitis.
  • Allergic rhinitis: The patient's history of using Allegra and Dymista, as well as the presence of mucosal thickening on the sinus CT, suggests underlying allergic rhinitis, which could be contributing to the patient's symptoms.
  • Sinusitis exacerbation: The patient's history of recurring acute rhinosinusitis episodes and the presence of mucosal thickening on the sinus CT suggest that the current episode could be an exacerbation of underlying chronic sinusitis.
• Do Not Miss diagnoses:
  • Orbital cellulitis: The patient's sharp pain around the top left side of the nose and left temple could be indicative of orbital cellulitis, a serious infection that requires prompt medical attention.
  • Cavernous sinus thrombosis: The patient's symptoms of facial pain and nasal congestion could be indicative of cavernous sinus thrombosis, a rare but potentially life-threatening complication of sinusitis.
  • Meningitis: The patient's symptoms of headache and facial pain could be indicative of meningitis, a serious infection that requires prompt medical attention.
• Rare diagnoses:
  • Fungal sinusitis: The patient's history of recurring sinusitis episodes and the presence of mucosal thickening on the sinus CT could suggest fungal sinusitis, a rare but potentially serious infection.
  • Nasal tumor: The patient's history of recurring sinusitis episodes and the presence of a retention cyst on the sinus CT could suggest a nasal tumor, a rare but potentially serious condition.

The patient's decision to discontinue the Augmentin due to side effects may have contributed to the development of antibiotic resistance, but the extent of this is unclear without knowing the results of the culture. If the culture comes back with no growth, the patient's symptoms could still be managed with supportive care, such as nasal saline irrigations and decongestants. If the ENT recommends resuming antibiotics, an alternative antibiotic that is not a sulfa drug could be considered. However, the patient's history of sensitivity to new medications and allergy to sulfa drugs may limit the options.