What is the diagnosis and next steps for a 27-year-old female with a history of diabetes (taking Sitagliptin + Metformin) and hyperlipidemia (taking Atorvastatin), presenting with recurrent watery nasal discharge, dyspnea, dry cough, sharp chest pain when coughing, and congested non-erythematous turbinates?

Diagnosis: Acute Bacterial Rhinosinusitis with Post-Nasal Drip Bronchitis

This 27-year-old woman has acute bacterial rhinosinusitis complicated by upper airway cough syndrome (post-nasal drip bronchitis), not primary acute bronchitis. 1

Clinical Reasoning

The temporal sequence confirms this diagnosis:

• Initial viral upper respiratory infection 2 months ago that resolved 2
• Recurrence 4 weeks ago with persistent symptoms now exceeding 10 days 2
• Nasal discharge settling in throat followed by dry cough with throat clearing represents the classic sino-bronchial syndrome pattern 1
• Sharp chest pain with coughing is musculoskeletal from repetitive coughing, not pneumonia 1
• Band-like headache during cough episodes is typical of increased intrathoracic pressure, not sinogenic headache 1
• Congested non-erythematous turbinates obstructing 50% of view confirms active rhinosinusitis 1

Critical Point: This is NOT primary acute bronchitis—the cough is secondary to post-nasal drip from untreated bacterial sinusitis. 1 The previous self-medication with decongestants and mucolytics addressed symptoms but not the underlying bacterial infection. 1

Immediate Management

Antibiotic Therapy

Start amoxicillin-clavulanate 875mg/125mg twice daily for 7-10 days as first-line therapy for acute bacterial rhinosinusitis. 3 This is superior to amoxicillin alone because the osteomeatal unit obstruction (evidenced by 50% turbinate obstruction) often harbors beta-lactamase producing organisms. 3

Alternative if penicillin allergy: Use respiratory fluoroquinolone (levofloxacin 500mg daily or moxifloxacin 400mg daily) for 7-10 days. 3

Adjunctive Therapy

• Intranasal corticosteroid spray (fluticasone 2 sprays each nostril twice daily or mometasone 2 sprays each nostril once daily) to reduce mucosal inflammation and improve sinus drainage 3, 1
• Continue nasal decongestant (phenylephrine) as needed, but limit to 10 days maximum to avoid rhinitis medicamentosa 3
• Adequate hydration to thin secretions 1
• Sleep with head elevated to improve drainage 3

What NOT to Do

Do NOT order chest X-ray—the cough is clearly secondary to post-nasal drip, not pneumonia. 1 The sharp chest pain is musculoskeletal from coughing, and she has no fever, dyspnea at rest, or systemic toxicity. 1

Do NOT order CT sinuses at this stage—she has clear clinical sinusitis with appropriate symptom duration (<4 weeks of current episode). 1 Reserve CT for treatment failure after appropriate antibiotics or suspected complications. 1

Special Considerations for This Patient

Diabetes Management

Her diabetes (on sitagliptin/metformin) requires attention during acute infection:

• Monitor blood glucose more frequently during acute illness 2
• Acute infection may temporarily worsen glycemic control 4
• Ensure adequate hydration given metformin use 4
• No antibiotic adjustment needed—amoxicillin-clavulanate has no significant interaction with sitagliptin/metformin 5

Atorvastatin Consideration

Continue atorvastatin 40mg—no interaction with recommended antibiotics and should not be interrupted. 5

Follow-Up Plan

Reassess in 48-72 hours (phone or in-person) to ensure symptom improvement. 1

Expected Response

• Nasal congestion should begin improving within 3-5 days 1
• Cough may persist 2-4 weeks but should gradually decrease in frequency and severity 1
• Complete resolution typically takes 2-4 weeks 1

Treatment Failure Criteria

If symptoms worsen or fail to improve after 3-5 days of antibiotics:

• Switch to respiratory fluoroquinolone (levofloxacin 500mg daily or moxifloxacin 400mg daily) for 14 days 3
• Now obtain coronal CT sinuses to evaluate for complications or anatomic obstruction 3, 1
• Consider ENT referral if CT shows significant osteomeatal complex obstruction 3

Red Flags Requiring Urgent Re-Evaluation

Return immediately or call if she develops:

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

Common Pitfalls to Avoid

• Don't misdiagnose as primary acute bronchitis—this leads to inappropriate antibiotic selection and missed treatment of the underlying sinusitis 1
• Don't rely on "feeling of phlegm stuck in throat" as indication for mucolytics alone—this symptom indicates post-nasal drip requiring treatment of the source (sinusitis) 1
• Don't prescribe prolonged nasal decongestants beyond 10 days (risk of rebound congestion) 3
• Don't overlook the 50% turbinate obstruction on exam—this indicates significant mucosal edema requiring intranasal corticosteroids, not just systemic therapy 3, 1