What are the next steps for a 44-year-old female patient with a 3-day history of cold and headache, sinus involvement, diabetes managed with Sitagliptin (Sitagliptin) and Metformin (Metformin), and hyperlipidemia managed with Simvastatin (Simvastatin), who has normal physical exam findings and finds temporary relief with inhaled Vicks (camphor, eucalyptus oil, and menthol)?

Diagnosis: Viral Rhinosinusitis (Common Cold)

This is a straightforward case of viral rhinosinusitis that requires symptomatic treatment only—antibiotics are not indicated and should not be prescribed. 1

Clinical Reasoning

Your patient presents with classic viral upper respiratory infection symptoms lasting only 3 days with:

• Headache distributed across sinus regions
• Intermittent pattern with brief resolution periods
• Aggravation by temperature changes
• Temporary relief with topical menthol (Vicks)
• Normal physical examination
• No fever, no severe unilateral pain, no "double sickening" pattern 2

The diagnosis is based on symptom duration and absence of bacterial infection criteria. Acute viral rhinosinusitis is defined as symptoms lasting less than 10 days without worsening, and this patient is only at day 3. 1, 2

Why This Is NOT Bacterial Sinusitis

Do not prescribe antibiotics. The American College of Physicians and CDC explicitly state that antibiotics should be reserved only for patients meeting specific criteria, none of which this patient has: 1

• Persistent symptoms for more than 10 days without improvement
• Severe symptoms with high fever (>39°C) AND purulent nasal discharge for at least 3 consecutive days
• "Double sickening" (worsening after initial improvement around day 5)

Your patient has none of these features. She is at day 3 with no fever documented and normal exam findings. 1, 2

Immediate Management Plan

Continue symptomatic treatment with the following specific recommendations: 1

• Combination antihistamine-analgesic-decongestant products provide significant relief in 1 out of 4 patients and are more effective than newer non-sedating antihistamines alone 1
• Analgesics (acetaminophen or NSAIDs like naproxen) for headache—naproxen specifically decreases cough, headache, and malaise in viral URIs 1
• Saline nasal irrigation for symptomatic relief 1
• Warm facial compresses and steamy showers 1
• Adequate hydration and rest 1
• Sleep with head elevated 1

Critical Follow-Up Instructions

Instruct the patient to return or call if: 1, 2

• Symptoms persist beyond 10 days without improvement (this would then meet criteria for post-viral rhinosinusitis and consideration of intranasal corticosteroids) 2
• Fever develops, especially >38°C 2
• Severe unilateral facial pain develops 2
• Initial improvement followed by worsening around day 5-7 ("double sickening") 2
• Symptoms have not improved within 3-5 days 1

Special Considerations for This Patient

Given her diabetes (on Sitagliptin/Metformin), monitor more closely for bacterial complications, though the risk remains low at 0.5-2% of viral URIs. 2 However, her normal physical exam and absence of fever are reassuring.

Avoid topical decongestants (like oxymetazoline) for more than 3 days due to risk of rhinitis medicamentosa. 1

What NOT to Do

Do not order imaging. CT or plain radiographs are not indicated for uncomplicated viral rhinosinusitis at day 3, as 87% of patients with recent-onset colds show sinus abnormalities on imaging that resolve without antibiotics. 1 Imaging abnormalities alone have no clinical specificity for bacterial infection within the first week. 1

Do not prescribe antibiotics. The number needed to harm from antibiotic adverse effects (8) is less than the number needed to treat for rapid cure (18) in acute rhinosinusitis. 1 Most patients have more adverse effects than benefits from antibiotics. 1

Expected Clinical Course

Reassure the patient that symptoms typically last up to 2 weeks, with approximately 25% of patients still having mild symptoms at day 14. 1, 2 This is normal and does not indicate bacterial infection or treatment failure. 1