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FM44 Family Medicine
Common Presenting Problems
Toronto Notes 2019
Symptoms of Sinusitis
Recurrent/ABRS
CT or refer for expert assessment
With multiple recurrent episodes, consider radiology (standard 3 view sinus x-ray or CT) to confirm ABRS during episode or to eliminate other causes
Mild to moderate
Intranasal corticosteroids (INCS)
>7 d
High likelihood of bacterial infection
Requires confirmation of two major symptoms
<7 d
Viral URTI
Treat symptomatically
If symptoms persist, worsen or change
For diagnosis of ABRS, patient must have
1. nasal obstruction or nasal purulence/discoloured postnasal
discharge and
2. at least one other PODS symptom
P Facial Pain/pressure/fullness
O Nasal Obstruction
D Nasal purulence/discoloured postnasal Discharge S Hyposmia/anosmia (Smell)
Consider ABRS under any one of the following conditions Worsening after 5-7 d (biphasic illness) with similar symptoms Symptoms persist more than 7 d without improvement Presence of purulence for 3-4 d with high fever
Identify level of severity
Clinical response in 72 h?
Severe
INCS and antibiotics
Clinical response in 72 h?
Yes No
Yes
Continue course
No
Consider antibiotics if symptom duration is >7 d
Continue course
Use second-line agent or change antibiotic class
Clinical response in 72 h?
Yes
No
For symptoms lasting more than 4 wk, consider chronic rhinosinusitis (CRS). Persistent severe symptoms require prompt urgent referral.
Figure 16. Diagnosis and management of sinusitis
ABRS = acute bacterial rhinosinusitis
Adapted from: Desrosiers M, et al. Allergy Asthma Clin Immunol 2011;7:doi:10.1186/1710-1492-7-2
Sleep Disorders
• seeRespirology,R32andNeurology,N46
Definition
• mostoftencharacterizedbyoneofthreecomplaints ■ insomnia
◆ difficulty falling asleep, difficulty maintaining sleep, early morning wakening, non-refreshing sleep
■ parasomnias
◆ night terrors, nightmares, restless leg syndrome, somnambulism (performing complex
behaviour during sleep with eyes open but without memory of event) ■ excessive daytime sleepiness
Epidemiology
• 1/3ofpatientsinprimarycaresettinghaveoccasionalsleepproblems,10%havechronicsleepproblems