What is the appropriate diagnosis and treatment approach for a patient presenting with a moderate severity condition, potentially complicated by comorbidities?

Selecting a Moderate Severity Case Study with Comorbidities for Graduate Medical Education

For a graduate medical program case study, I recommend acute bacterial sinusitis with persistent symptoms after initial treatment in a patient with moderate comorbidities—this provides an ideal teaching scenario that balances diagnostic complexity, treatment decision-making, and comorbidity management without overwhelming learners.

Why This Case Works for Graduate Education

Appropriate Complexity Level

• Acute sinusitis with persistent symptoms represents a moderate severity problem that requires antibiotic escalation and adjunctive therapy, making it neither too simple nor excessively complex for graduate learners 1
• The condition allows for discussion of when to initiate antibiotics versus watchful waiting, teaching clinical judgment in real-world scenarios 1
• Students can learn to recognize treatment failure and adjust therapy accordingly, which is a critical clinical skill 1

Comorbidity Integration Options

• Cardiovascular comorbidities: The case can include hypertension or mild heart disease, requiring careful selection of decongestants and NSAIDs 1
• Respiratory comorbidities: Adding mild COPD or asthma allows discussion of how intranasal corticosteroids interact with existing respiratory conditions 1
• Drug allergies: Including penicillin allergy teaches alternative antibiotic selection (doxycycline, trimethoprim-sulfamethoxazole, or macrolides) 1, 2

Specific Clinical Presentation to Use

Patient Demographics and History

• Age 45-65 years with 20+ pack-year smoking history (allows discussion of lung cancer screening eligibility as a tangential teaching point) 3
• Present with 10-14 days of facial pain, purulent nasal discharge, and nasal congestion that initially improved with symptomatic treatment but then worsened 1
• Include 2-3 comorbidities such as hypertension, type 2 diabetes, and hyperlipidemia to add realistic complexity without making the case unmanageable 4, 5

Key Physical Examination Findings

• Maxillary sinus tenderness to percussion 1
• Purulent nasal discharge visible on anterior rhinoscopy 1
• Vital signs showing low-grade fever (100.5-101°F) indicating bacterial infection 1
• Blood pressure 145/92 mmHg (if including hypertension as comorbidity) 5

Treatment Algorithm to Teach

First-Line Antibiotic Therapy

• Initiate amoxicillin 500mg three times daily for 7-10 days as first-line therapy due to efficacy, safety, and cost-effectiveness 1
• For penicillin allergy: doxycycline, trimethoprim-sulfamethoxazole (adults), or macrolides 1, 2
• Critical teaching point: Azithromycin requires careful consideration due to QT prolongation risk, especially in patients with cardiovascular comorbidities, electrolyte abnormalities, or concurrent QT-prolonging medications 2

Adjunctive Symptomatic Management

• Continue analgesics (acetaminophen preferred over NSAIDs if cardiovascular disease present) 1
• Add intranasal corticosteroids to reduce inflammation and improve symptoms 1
• Consider short-term decongestants (topical or systemic) with caution in hypertensive patients 1
• Recommend saline nasal irrigation to clear secretions 1

Monitoring and Follow-up Decision Points

• If no improvement within 3-5 days: Switch to amoxicillin-clavulanate for broader spectrum coverage 1
• If symptoms worsen with high fever, severe headache, or visual changes: Immediate evaluation for complications (orbital cellulitis, meningitis, brain abscess) 1
• Expected timeline: Complete resolution may take 10-14 days even with appropriate treatment 1

Educational Value and Learning Objectives

Clinical Reasoning Skills

• Students learn to distinguish viral from bacterial sinusitis based on symptom duration and progression 1
• The case teaches when to escalate from symptomatic treatment to antibiotics 1
• Learners practice recognizing treatment failure and adjusting therapy systematically 1

Comorbidity Management Integration

• Cardiovascular considerations: Avoiding vasodilating agents that could worsen hypotension, careful decongestant use in hypertension 6, 1
• Medication interactions: Understanding QT prolongation risk with macrolides in patients on other QT-prolonging drugs 2
• Renal function: Adjusting antibiotic dosing in patients with chronic kidney disease 6

Common Pitfalls to Highlight

• Premature antibiotic use: Not all sinusitis requires antibiotics; viral cases resolve with symptomatic treatment alone 1
• Inadequate treatment duration: Stopping antibiotics too early leads to recurrence 1
• Ignoring red flags: Missing signs of complications (severe headache, visual changes, altered mental status) can lead to serious morbidity 1
• Macrolide overuse: Azithromycin carries significant cardiac risks that are often underappreciated, particularly in elderly patients or those with cardiovascular comorbidities 2

Alternative Moderate Severity Cases (If Sinusitis Doesn't Fit)

Benign Prostatic Hyperplasia with Moderate Symptoms

• Presentation: 65-year-old male with AUA Symptom Score 12-18, bothered by nocturia and weak stream 6
• Comorbidities: Hypertension, type 2 diabetes 6
• Treatment algorithm: Alpha-blocker (tamsulosin, alfuzosin) versus 5-alpha-reductase inhibitor (finasteride) versus combination therapy, with consideration of cardiovascular effects 6
• Educational value: Teaches shared decision-making, as treatment choice depends heavily on patient preference regarding side effects versus efficacy 6

Hypertrophic Obstructive Cardiomyopathy (Mild-Moderate Symptoms)

• Presentation: 50-year-old with exertional dyspnea and chest pressure, LVOT gradient 50-70 mmHg 7
• Comorbidities: Atrial fibrillation, hypertension 7
• Treatment algorithm: Beta-blocker titration to heart rate <60 bpm, then verapamil if inadequate response, then disopyramide with careful QTc monitoring 7
• Educational value: Teaches medication selection based on hemodynamics and the critical importance of avoiding vasodilators in obstructive physiology 7

Aortic Stenosis (Moderate Severity)

• Presentation: 70-year-old with exertional dyspnea, mean gradient 30-40 mmHg, AVA 1.0-1.5 cm² 6
• Comorbidities: Coronary artery disease, chronic kidney disease 6
• Diagnostic approach: Exercise stress testing to unmask symptoms, assessment of surgical versus TAVR candidacy 6
• Educational value: Teaches risk stratification, multidisciplinary team decision-making, and when intervention is contraindicated due to comorbidities limiting life expectancy 6

Practical Implementation for Case Study

Case Structure

1. Initial presentation: Patient demographics, chief complaint, symptom timeline 1
2. History of present illness: Detailed symptom progression, previous treatments tried 1
3. Past medical history: 2-3 relevant comorbidities with current medications 4, 5
4. Physical examination: Specific pertinent positive and negative findings 1
5. Assessment questions: What is the diagnosis? What treatment would you initiate? What monitoring is needed? 1
6. Follow-up scenario: Patient returns in 4 days with no improvement—what do you do next? 1

Discussion Points for Faculty

• Evidence-based antibiotic selection and duration 1
• Risk-benefit analysis of adjunctive therapies in patients with comorbidities 1, 2
• Recognition of treatment failure and systematic approach to escalation 1
• Patient education regarding expected timeline and warning signs 1
• Cost-effectiveness considerations in antibiotic selection 1