Help with diagnosis

Discussion in 'Medical Students - MD' started by Entol, Apr 28, 2004.

  1. Entol

    Entol Senior Member
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    My mother has had problems with her sense of smell for the past month and wanted a second opinion on these symptoms. If anyone might have an idea, let me know. Also, if any more info can be helpful, I can give it :)

    Symptoms
    -----------
    Complete loss of sense of smell
    Stuffy nose
    Mucus from nose is yellowish-green, very thick

    Family doctor originally she might have a sinus infection, but after taking antibiotics, the symptoms didn't go away. Allergy pills also did not work. Her doctor now thinks it might be damage to the nerve itself and that the loss of smell might be permanent. She is a 55 yo female. No injuries to head or anything like that, and she doesn't generally have allergies this strong if at all.

    Anyone have any ideas on what this could be?
     
  2. doc05

    doc05 2K Member
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    What was the pe? Has nasopharyngoscopy been done?

    If she is still suffering from purulent rhinorrhea despite abx, then it's time for new abx. Consider sinus CT if the 2nd course of abx fails.
     
  3. drcrusher

    drcrusher DrCrusher
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    Is your mother a diabetic?
     
  4. Entol

    Entol Senior Member
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    nope, not diabetic.. no history of it in our family either!
     
  5. Entol

    Entol Senior Member
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    D'oh, sorry I'm not sure what PE is-- still a pre-med student :) and she hasn't done any sort of invasive thing like nasopharyngoscopy. She's only seen our family physician, so I assume the invasive stuff would be performed by a specialist if she is referred to one later.

    Also, she said that she does not have a significantly large amount of nasal discharge. Rather, her nose is stuffy, if that makes any sense. When she does blow her nose though, the phlegm is yellowish-green.

    The physician hasn't put her on any new antibiotics, so I'm a bit worried if that's what should be done. Should she request to see a specialist in the field or just trust the family physician to refer her?



     
  6. Idiopathic

    Idiopathic Newly Minted
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    Any meds? Its rare, but ACE inhibitors (ends in -pril) have been known to cause loss of smell and taste in people, and I recently diagnosed this in my father in law, only to be confirmed by his doc. They were alos looking at CT if his situation didnt clear up, but they had placed him on some steroids prior to that.
     
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  7. entpa

    entpa Member
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    She should see an ENT. Most likely chronic sinusitis. Someone already mentioned a second course of anbx and then a CT.
     
  8. aj725

    aj725 Member
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    Since the sinus topic came up--what do they look for on a sinus CT (an underlying infection or something else)? I've had pain on the left side of my face right on the cheekbone for a few months now; it comes and goes isn't sharp and seems to have something to do with the weather at times. However, it does radiate to the left ear at times, and I've had 2 sinus infections in the last 6 months--so is it a bad idea to chalk this up to allergies (it doesn't seem like an infection--tons of discharge but completely clear). I avoid going to the doctor as much as possible, esp. when I know she'll say well it could be allergies or an infection--i mean isn't there a better way to determine what this is!?!?
     
  9. Seaglass

    Seaglass Quantum Member
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    Short answer-stuff in the sinuses. Actually CT is very good (compared to std. xray)for chronic sinusitis and will show inflammation of the sinus mucosa.
     
  10. pikachu

    pikachu Senior Member
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    PE = Physical exam

    Is it a TOTAL lack of the sense of smell (i.e., you hold a bag of coffee under her nose with her eyes closed and she can't identify the smell)? Is the rhinorrhea from only one nostril or is it bilateral? Is she a smoker? What medicines is she on?

    If she were my patient, I would look for:
    1) tenderness over the cheekbones or forehead
    2) any enlarged lymph nodes in the head and neck region
    3) hearing changes or hearing loss
    4) cranial nerve/other neurologic abnormalities

    Possibilities that I would be thinking about in this case are nasal polyps or obstruction due to sinusitis; zinc deficiency; medication side effect; intracranial (involving olfactory pathways) or intranasal mass.

    Because of the anosmia, I think she would benefit from an ENT evaluation with a focused exam of her nasopharynx, sense of smell, and a thorough neurologic exam. She also may need a head and sinus CT. This will be even more true if she fails to respond to another course of broad spectrum antibiotics.

    Please keep us posted, Entol.
     
  11. Entol

    Entol Senior Member
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    Should she specifically ask to be referred to a specialist or should she look for one herself? Also, should she request different antibiotics if she feels these aren't working?
     
  12. DocWagner

    DocWagner Senior Member
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    I am responding only because the topic looked interesting...


    Guys, but what is the point of pissing in the wind with the antibiotics, when "bacterial sinusitis" is overly diagnosed. The patient has a significant complaint and I would order a facial/sinus CT without hesitation.

    The number one reason for failure in bacterial sinusitis is too short of a course of antibiotics (typically 2 weeks), the next reason is inaccurate diagnosis.
     
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  13. MustafaMond

    MustafaMond K-Diddy M.D.
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    Speaking of pissing in the wind- What's the point of getting a CT Scan?
    We know what it will show.

    Just tell your mom to request another course of AbX, and Allegra-D samples. She probably has a component of allergic sinusitis.

    CT scans, and expensive specialists that cram scopes in your face, and the other diagnoses mentioned (Brain tumour? WTF!!!) are only necessary if the problem is CHRONIC (defined by Harrison's as 3 months duration).

    Good thought about medication induce (ACE-I), butbefore chasing a Kallman's syndrome, or some ZZebra, I'd treat her adequately and give her time, first
     
  14. Singh

    Singh Senior Member
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    Has the doctor taken smears for microscopic investigation and culture?
    It could be a bacterial infection which isn't responding to the given antibiotica (in which case a resistanceinvestigation is necessary).
     
  15. Kalel

    Kalel Membership Revoked
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    Chronic sinusitis is one possibility. Another is non-allergic rhinitis; tell her to ask her doctor for a trial of nasal steroids, ipratroprium(atrovent) nasal spray, and check a TSH if the head CT is normal. If the head CT shows something like chronic sinusitis, she may want to be referred to an allergist. Chronic sinusitis can be challenging to treat. Augmentim for 3-4 weeks works for some. It's stupid for her FP to suggest that her loss of smell may be permanent without knowing what is actually causing it; I'd find a new doctor if I were her.
     
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  16. Entol

    Entol Senior Member
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    Hey Pikachu,

    In response to some of your questions: She is a smoker, fairly heavy, for almost 30 yrs now. She says she has complete loss of smell, which is very scary. and rhinorrhea from both nostrils. She is only taking the antibiotics right now, and nothing else too important. Vitamin C tablets too I think.

    As for the hearing, I talked to her and she had a slight loss in hearing, but nothing as severe as the sense of smell. :(

    She said she'll ask her doctor for different antibiotics, so thanks a lot for this idea everyone! She also said that her doctor didn't seem to believe that it was severe enough to refer her to a specialist, so she's going to try to find one herself. Again, thanks for this idea! :)


     
  17. Entol

    Entol Senior Member
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    She says she's only had the problem for a month and a half now (and knowing my mother, she tends to exaggerate so I'm guessing more like 1 month?). I hope it's nothing serious, but her family doc seems to be agreeing with this plan-- to wait and see if things improve.

    CT scans are a bit expensive, and I'm not sure if her insurance will cover something like this. If it's worthwhile though, I'll tell her to ask her doctor for sure.

    I also talked to her about requesting the Allegra-D.. she said she's allergic to Allegra. I'm not sure if this means she'll also be allergic to Allegra-D, but I'm going to do a search online on Allegra-D tonight and let her know. Thanks :)


     
  18. omores

    omores sleep deprived
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    If she's allergic to allefra, she's allergic to allegra-D: it's the same drug, but with pseudoephedrine added (decongestant). Might be worth finding out if it's a true allergy or just bad side effects, for future reference.

    I'd probably go with nasal fluticasone (Flonase), a topical corticosteroid that can knock back the swelling and inflammation and help drainage.

    By the way, even if she does have allergic rhinitis w/ secondary infection, the smoking isn't helping at all. Smoking is well known to reduce olfactory acuity (to use a pretentious phrase). She probably had a not-very-good sense of smell baseline, and then this knocked it out altogether.
     
  19. realruby2000

    realruby2000 Senior Member
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    i usually lose my sense of smell during august due to seasonal allergies wreaking havoc on my sinuses. Try putting her on Flonase ( nasal corticosteroids). Mine cleared up a few days. It was wonderful.
     
  20. Entol

    Entol Senior Member
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    I just wanted to say thanks for all those med students who responded with ideas! I think it's great to have these second opinions, since sometimes your family doc might not be paying attention to specific details in what you say. I read all the responses to my mom over the phone, and she's hoping to find a specialist herself now, without waiting for a referral. Also, she requested another appointment with her doctor to ask for different antibiotics and see if any other drugs (two people mentioned Flonase) might help out. Thanks a lot!

    :) :) :)
     
  21. quackdoc

    quackdoc Member
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    Hi,
    I have seen the responses and this isnt the final word but a greenish coloured nasal discharge from the nasal cavity does point to bacterial infection.
    Is there any history of blocked nose prior to the infection(if that is assumed).
    Usually there is a viral component and makes it easier for the bacteria to invade.
    Previous history of smoking adds insult to injury.
    A simple plain Xray can provide relevant information.If the inflammation is the component then the mucosa will be enlarged.CT scans are indicated if there is suspicion of carcinoma and to diagnose the extent of the same.I would recommend maxillary antrostomy or cad-wel-luc operation or FESS which can give the required information by ensnaring the mucosa and culturing it if bacterial infection is suspected.
    As for the allergies I repose my faith in the new generation non sedative antihistamines-Fexofenadine or Ebastine.Cetrizine is out.
    One thing that wasnt mentioned is the steam inhalation.Its very effective and helps to loosen the mucus out.
    As for the anosmia its not always the olfactory nerve thats knocked out.There maybe several causes chief among them would be allergic rhinitis,bacterial sinusitis and nasal polyps.A simple indirect laryngoscopy would reveal if there is underlying nasal polyp too or not.
    As for the antibiotic course the most likely organism thats producing the greenish yellow flow is pseudomonas or klebsiella.A course of Ofloxacin is what I would recommend.
    Heres wishing your mother a speedy recovery.
     
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