What is the next best step for a 37-year-old female with a history of hypertension (on Irbesartan 150 mg OD) and goiter (on Levothyroxine 50 mcg OD), who works in a dusty warehouse, presenting with persistent symptoms of nasal discharge, cough, and intermittent frontal headache, despite being on N-Acetylcysteine (NAC) 600 mg, Levocetirizine + Montelukast 5mg/10mg, and Co-Amoxiclav 625 mg Q8 with meals for a diagnosed Upper Respiratory Tract Infection (URTI)?

Diagnosis: Allergic Rhinitis with Occupational Triggers

This patient has allergic rhinitis with occupational exposure triggers, not a persistent bacterial infection, and requires a complete change in management strategy away from antibiotics toward intranasal corticosteroids and environmental controls.

Clinical Reasoning

The presentation strongly suggests allergic rhinitis rather than persistent URTI or bacterial sinusitis:

• Bilateral turbinate swelling with nasal obstruction on physical exam is characteristic of allergic rhinitis, not infection 1
• Symptoms triggered by dusty warehouse environment indicate occupational allergen exposure 1
• Normal chest X-ray rules out lower respiratory complications 1
• Failure to respond to appropriate antibiotic therapy (Co-Amoxiclav) after adequate duration suggests non-bacterial etiology 1
• Intermittent frontal headache relieved by rest is consistent with sinus pressure from allergic inflammation rather than acute bacterial sinusitis 1

The current antibiotic regimen is inappropriate because:

• Antibiotics are not indicated for viral URTI or allergic rhinitis 1
• Co-Amoxiclav should only be used for confirmed bacterial infections 2, 3
• Continued antibiotic use without bacterial confirmation increases resistance and adverse effects 1

Immediate Management Changes

Discontinue Current Medications

Stop Co-Amoxiclav immediately - there is no indication for continued antibiotic therapy given normal imaging, lack of bacterial infection criteria, and treatment failure 1

Critical consideration for this patient: She has hypertension on Irbesartan. The current Levocetirizine + Montelukast combination likely contains pseudoephedrine as a decongestant component, which should be avoided in hypertensive patients 4, 5

First-Line Treatment Recommendations

Initiate intranasal corticosteroids as primary therapy - this is the most effective treatment for allergic rhinitis and safe for hypertensive patients 1, 4, 5

• Continue for minimum 3 months for chronic symptoms 1
• Demonstrate proper administration technique: prime bottle, shake before use, blow nose first, keep head upright, hold spray in opposite hand to nostril being treated, aim away from septum 1

Continue Levocetirizine alone (without pseudoephedrine/decongestant) - second-generation antihistamines are safe in hypertension and effective for rhinorrhea and sneezing 1, 4, 5

Discontinue Montelukast - oral leukotriene receptor antagonists are not recommended as primary therapy for allergic rhinitis 1. While combination therapy with antihistamines shows some benefit 6, 7, intranasal corticosteroids are superior and should be first-line 1

Continue NAC - may provide symptomatic relief for mucus clearance, though evidence is limited 1

Environmental Controls (Critical for Occupational Exposure)

Implement workplace modifications 1:

• Use of high-efficiency particulate air (HEPA) filter masks during warehouse work
• Improved ventilation in dusty areas
• Consider air filtration systems if feasible
• Minimize direct exposure to dust triggers

When to Consider Bacterial Sinusitis

Bacterial sinusitis should only be diagnosed if symptoms meet specific criteria 1:

• Persistent symptoms >10 days without improvement, OR
• Severe symptoms (fever >39°C, purulent discharge, facial pain) for ≥3 consecutive days, OR
• "Double sickening" - worsening after initial improvement

This patient does not meet any of these criteria 1.

Diagnostic Testing Recommendations

Perform specific IgE allergy testing (skin or blood) because 1:

• Diagnosis is uncertain despite clinical presentation
• Patient has not responded to empiric treatment
• Knowledge of specific allergens will guide targeted environmental controls
• Occupational allergen identification is essential for workplace modifications

Do NOT perform sinus imaging - routine imaging is not indicated for allergic rhinitis diagnosis 1

Follow-Up Plan

Reassess in 2-4 weeks to evaluate response to intranasal corticosteroids 1

If symptoms persist despite optimal medical therapy and environmental controls:

• Refer to ENT or allergist for consideration of immunotherapy (sublingual or subcutaneous) 1
• Consider inferior turbinate reduction only after failed medical management 1

Critical Pitfalls to Avoid

Never combine multiple decongestants in this hypertensive patient - risk of hypertensive crisis 4, 5, 8

Avoid topical nasal decongestants (oxymetazoline) beyond 3 days - causes rhinitis medicamentosa with rebound congestion 1, 8

Do not use NSAIDs (ibuprofen, naproxen) for symptom relief - they elevate blood pressure 3-6 mmHg and antagonize antihypertensive medications including her Irbesartan 5

Monitor blood pressure given medication changes and ensure hypertension remains controlled 4, 5