What are the next steps and possible diagnosis for a 61-year-old female patient with a chief complaint of cough and colds, presenting with thick and greenish nasal discharge, maxillary and ethmoid sinus pain, productive cough with sticky green phlegm, and throat discomfort, with a past medical history of hypertension, currently taking [MEDICATION] (generic name), and laboratory results showing a 5.0% ASCVD (Atherosclerotic Cardiovascular Disease) risk, normal ECG (Electrocardiogram) with abnormal wave morphology in Lead V3, and physical examination revealing swollen non-erythematous turbinates?

Acute Bacterial Rhinosinusitis with Post-Nasal Drip Bronchitis

This patient has acute bacterial rhinosinusitis that has progressed to post-nasal drip-induced bronchitis, and should be treated with azithromycin 500 mg once daily for 3 days. 1, 2

Clinical Diagnosis

Acute Bacterial Rhinosinusitis:

• The thick, greenish nasal discharge with maxillary and ethmoid sinus pain lasting 1 week indicates acute bacterial sinusitis 1
• Swollen non-erythematous turbinates on physical examination support this diagnosis 3
• The progression from nasal discharge to throat settling with subsequent productive cough represents the classic sino-bronchial syndrome pattern 3

Post-Nasal Drip Bronchitis:

• The productive cough with sticky green phlegm developing 3 days prior to consultation represents acute bronchitis secondary to upper airway cough syndrome (UACS) from the sinusitis 1
• The temporal sequence—nasal discharge waning and settling in throat, followed by productive cough—confirms post-nasal drip as the mechanism 1
• This is NOT primary acute bronchitis, which would be overdiagnosed if the common cold/sinusitis component is not recognized first 1

Immediate Management

Antibiotic Therapy:

• Azithromycin 500 mg once daily for 3 days is the appropriate treatment for acute bacterial sinusitis 2
• This regimen achieved 71.5% clinical cure rate at Day 28 for acute bacterial sinusitis, comparable to 10 days of amoxicillin/clavulanate 2
• The likely pathogens are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 2

Symptomatic Treatment:

• Continue nasal decongestant as needed for symptom relief 1
• Add intranasal corticosteroid spray (e.g., fluticasone or mometasone) to reduce mucosal inflammation and improve drainage 1
• Encourage adequate hydration to thin secretions 1

Diagnostic Workup

No Imaging Required Initially:

• CT sinus imaging is NOT indicated at this stage since the patient has clear clinical sinusitis with appropriate symptom duration (<4 weeks) 1, 3
• Reserve CT scanning for persistent symptoms after appropriate antibiotic therapy or if complications are suspected 1

Chest X-Ray NOT Indicated:

• The cough is clearly secondary to post-nasal drip, not primary pneumonia 1, 4
• No fever, dyspnea, hypoxemia, or systemic toxicity to suggest pneumonia 4
• The productive cough with green phlegm reflects sinus drainage, not lower respiratory infection 1

ECG Follow-Up:

• Repeat ECG to clarify the abnormal wave morphology in Lead V3 once acute illness resolves 1
• This is unrelated to the current acute presentation but requires documentation for cardiovascular risk assessment 1

Cardiovascular Risk Context

ASCVD Risk Assessment:

• The 5.0% 10-year ASCVD risk is low-risk category and does not require immediate intervention beyond hypertension management 5, 6
• Continue current antihypertensive medication 7
• No additional cardiovascular workup needed at this visit 5

Follow-Up Plan

Reassessment Timeline:

• Clinical reassessment in 48-72 hours by phone or in-person to ensure symptom improvement 4
• If symptoms worsen or fail to improve after 3-5 days of antibiotics, consider treatment failure and evaluate for complications 1
• Complete resolution may take 2-4 weeks; persistent symptoms beyond this warrant CT sinus imaging 1

Red Flags Requiring Urgent Re-Evaluation

• High fever (>39°C) or fever persisting beyond 72 hours of antibiotic therapy 4
• Severe unilateral facial pain or swelling suggesting orbital or intracranial complications 1
• Visual changes, severe headache, or altered mental status 1
• Hemoptysis or significant dyspnea 4
• Worsening symptoms after initial improvement 1

Common Pitfalls to Avoid

Do Not Misdiagnose as Primary Acute Bronchitis:

• The nasal symptoms and sinus pain clearly preceded the cough, making this secondary bronchitis from post-nasal drip 1
• Treating as isolated bronchitis without addressing the sinusitis will result in treatment failure 1

Do Not Prescribe Prolonged Antibiotics:

• The 3-day azithromycin regimen is sufficient; 10-14 day courses are unnecessary and increase adverse effects 2
• Gastrointestinal side effects (diarrhea 17%, nausea 7%) are common but generally mild 2

Do Not Order Unnecessary Imaging:

• CT sinuses are not indicated for uncomplicated acute bacterial sinusitis of <4 weeks duration 1, 3
• Chest X-ray is not warranted given the clear upper airway source of cough 1, 4