NU-664B Telehealth Transgender.

NU-664B Telehealth Transgender.

NU-664B Telehealth Transgender.

HPI: An otherwise healthy 35-year-old transgender woman on hormone suppressant therapy
presents with a chief complaint of sinus congestion and runny nose that began 2 days ago. She
tells you that her sinus infections always start off this way, and she has a wedding to go to this
coming weekend and does not want to be sick for this event. She is requesting antibiotics and is
quite insistent that she requires this treatment.

In the above presented case, the nurse practitioner would want to gather additional subjective
information from the patient to elicit important details in developing a differential diagnosis and
treatment plan. According to Dunphy et al. (2019), rhinitis can have several different etiologies
including atrophic, medication related, hormonal, infectious, or irritant related causes. Therefore,
the nurse practitioner would want to ask
Have you tried any over the counter or prescription medications or supplements to help relieve
symptoms? Use of afrin nasal spray for more than 3-4 days can lead to rebound nasal congestion
(Dunphy et al.,2019)

How long have you been on hormone suppressant therapy? Have you had any recent lab tests?
Fluctuations in estrogen levels may cause nonallergic rhinitis (Dunphy et al.,2019).
Have you had a fever? Could you describe the nasal discharge? What is the color and quality
including thickness? Do you have facial pain? According to Frerichs and Brateanu (2020),
bacterial rhinosinusitis is suspected with fever high than 102 degrees Fahrenheit, purulent nasal
discharge, and facial pain lasting 3 or more days.
Do you use any recreational drugs? According to Dains et al. (2016), acute or chronic cocaine
use can cause rebound nasal congestion.
Have you been diving or swimming? This can help elicit possible causes such as an allergic
response to chlorine exposure, infection from contaminated water, or barotrauma from diving
(Dains et al.,2016).

In biological women it would always be important to inquire about possibility of pregnancy as
pregnancy can cause nasal congestion due to hormonal changes (Dains et al.,2016). Pregnancy
status would also need to be known prior to prescribing any medications.
Do your symptoms change with position changes? If the symptoms worsen with bending or
leaning forward this suggests maxillary sinusitis (Dains et al.,2016).
Are your symptoms cyclic and seasonal? Do you have sneezing, or itching, or burning eyes? If
patient responds positively to these questions it would be suggestive of allergic rhinitis (Dains et
al.,2016)
Are the symptoms on one or both sides? Bilateral symptoms would indicate allergic or infectious
etiology while unilateral symptoms may be caused by nasal polyps, unilateral choanal atresia,
foreign body, or septal deviation (Dains et al.,2016).
Do you have any impairment in your ability to smell? Atrophic rhinitis may cause anosmia or a
foul odor (Dunphy et al.,2019).
Have you taken an at home covid-19 test? Have you been exposed to anyone with covid-19?
Covid-19 can present with rhinorrhea and nasal congestion (Reiss et al., 2020).

References

Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical
diagnosis in primary care. St. louis, MO: Elsevier mosby.
Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2019). Primary Care (5th
ed.). F. A. Davis Company.

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The differential diagnosis for this patient would include acute viral rhinosinusitis, acute bacterial

NU-664B Telehealth Transgender.
NU-664B Telehealth Transgender.

rhinosinusitis, allergic rhinitis, hormonal related rhinitis, nasal polyps, foreign body, septal
deviation, or covid-19.  Acute viral rhinosinusitis, acute bacterial rhinosinusitis, covid-19,
rhinitis medicamentosa, and allergic rhinitis all need to be considered because these are the
common causes of inflammation of the nasal and sinus mucosa which lead to the presentation of
the symptoms the patient is experiencing including rhinitis and sinus pressure (Goldsobel et al.,
2019). The other consideration with this particular patient would be rhinitis due to the fact that
the patient is on hormonal therapy because fluctuations in estrogen levels may cause rhinitis
(Dunphy et al.,2019). Nasal polyps, foreign bodies, or septal deviation can lead to a feeling of
pressure or blockage (Dunphy,2019).  Acute viral rhinosinusitis would be at the top of the list of
differentials because 95 percent of acute rhinosinusitis cases are caused by viruses that are
responsible for uncomplicated upper respiratory infections (Dunphy et al.,2019). According to
Dunphy (2019), ruling in the diagnosis of rhinosinusitis is based off a history of upper
respiratory symptoms for at least 7 days with the presence of two or more of the following:
headache, sinus or facial pain, lack of response to decongestants, and nasal secretions that are
colored. The differentiation between viral sinusitis and the possibility that the condition is
complicated by bacterial rhinosinusitis is made based on presentation of symptom severity in
addition to length of duration of symptoms. When the duration of symptoms has been over a
week to ten days the chances of bacterial sinusitis are more likely (Dunphy, 2019). The only
definitive way of identifying the causative organism would be a sinus aspiration however, this is
not commonly done in practice due to the invasive nature of the procedure (Dunphy,2019). At
this time covid-19 testing is readily availably so I would use a covid-19 rapid antigen test to help
rule in or out that diagnosis.  A physical examination would help to rule out nasal polyps, septal
deviation, or foreign body contributing to symptoms (Dunphy,2019). Physical exam would also
be useful in ruling in or out allergic rhinitis. Typically, in allergic rhinitis the nasal mucosa is
pale and edematous or may have a bluish hue and the conjunctiva of the eyes may also be

inflamed. In the history the patient may report itching, frequent sneezing, or a cyclic pattern to
symptoms.  The patient history and hormone screening labs would help rule in or out the
possibility of rhinitis caused by hormonal fluctuations (Dunphy,2019). Rhinitis medicamentosa
would be ruled out by taking a careful history that involves inquiring about the use of any over
the counter or prescription topical vasoconstrictive medications (Dunphy,2019). The patient in
this case has not used any over the counter or prescription medications which rules out the
diagnosis of rhinitis medicamentosa.
After assessing this patient based on the history provided including the duration and severity of
symptoms, I would treat this patient for viral rhinosunisitis. I would recommend that the patient
use saline nasal spray twice a day to improve sinus drainage (Dunphy, 2019). The patient should
also increase fluid intake and rest. Using heated mist from a hot shower or bath for steam
inhalations can help liquefy secretions which will improve nasal and sinus pain. I would also
recommend the use of a neti pot for nasal irrigation.  For the nasal congestion I would
recommend that the patient use afrin one to two sprays in each nostril three time a day as needed
to be used for 3-4 days only (Dunphy,2019). Due to this patient’s history of elevated blood
pressure readings, I would prefer to try a nasal spray prior to Sudafed due to the fact that Sudafed
can elevate blood pressure. I would advise the patient to use guaifenesin 400 mg every 4 hours as
needed because this help will to facilitate drainage of sinus secretions by liquefying them
(Dunphy, 2019). For this patient I would educate that the majority of cases of rhinosinusitis are
caused by viral infection and that only about 0.5% of all upper respiratory infections are
complicated by bacterial infection therefore, there is no medical benefit to antibiotics in this case
and there are risks involved with taking unnecessary antibiotics. I would instruct the patient to
notify the office if symptoms failed to improve by 7-10 days or if symptoms worsen. I would
instruct the patient to also contact the office with worsening facial pain, fever, or if purulent
nasal discharge occurred (Dunphy, 2019). I would discuss with the patient that viruses are
contagious so I would recommend avoiding contact with others to reduce the spread of the
illness (Dunphy,2019). I would recommend that the patient should follow up with the specialist
that is providing hormone therapy as levels should be checked. I would not recommend labs or
imaging at this time however, if symptoms continued for more than 10 days and were worsened,
I would consider antibiotic therapy. Referral to an ENT specialist would be indicated if
symptoms still failed to resolve with antibiotic therapy (Dunphy,2019).
In addressing health maintenance, the patient reported using recreational marijuana and I would
encourage the patient to refrain from smoking as the inhaled smoke can be an irritant and
exacerbate the symptoms that are being reported and lead to developing nasal and sinus
symptoms more frequently (Dunphy, 2019). I would also take this opportunity to review the
patient’s immunizations and if covid-19 vaccinations and/ or influenza vaccinations were not up
to date I would recommend receiving them when symptoms resolve to prevent development of
illness in the future.
In addressing the social determinants of health, I would consider the fact that transgender women
may be more prone to experience homelessness, unemployment, and poverty (Garcia & Crosby,
2020). Environmental factors can predispose patients to frequent sinus and nasal problems due to
contact with allergens and irritants (Dunphy,2019). I would ask about any problems with the

home environment and refer the patient to appropriate resources to assist with housing problems
if necessary.

References

Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2019). Primary Care (5th
ed.). F. A. Davis Company.
Garcia, J., & Crosby, R. A. (2020). Social Determinants of discrimination and access to health
care among transgender women in Oregon. Transgender Health, 5(4), 225–233.
https://doi.org/10.1089/trgh.2019.0090
Goldsobel, A. B., Prabhakar, N., & Gurfein, B. T. (2019). Prospective trial examining safety and
efficacy of microcurrent stimulation for the treatment of sinus pain and congestion. Bioelectronic
Medicine, 5(1). https://doi.org/10.1186/s42234-019-0035-x