Presenting Complaints

• Nasal congestion for the past 3 months

History of Presenting Complaint

• The patient reports persistent nasal congestion, making it difficult for him to breathe through his nose. He describes a constant feeling of stuffiness and occasional clear nasal discharge.
• He denies any recent upper respiratory tract infections, fever, or facial pain/pressure.
• Symptoms are present throughout the day and do not seem to be triggered by any specific activities or exposures.
• He has tried over-the-counter decongestant nasal sprays, which provide temporary relief but the congestion returns shortly after stopping the medication.

Significant Positives & Negatives For Differentials

Allergic Rhinitis

Positives:

• Persistent nasal congestion without fever or facial pain/pressure
• Lack of response to decongestant sprays

Negatives:

• Symptoms are not triggered by specific exposures
• No associated symptoms like sneezing, itchy/watery eyes, or postnasal drip

Nasal Polyps

Positives:

• Persistent nasal congestion without infectious symptoms
• Lack of response to decongestant sprays

Negatives:

• Symptoms are more diffuse and not localized to one side of the nose
• No history of recurrent sinus infections

Deviated Nasal Septum

Positives:

• Persistent nasal congestion without infectious symptoms
• Lack of response to decongestant sprays

Negatives:

• Symptoms are more diffuse and not localized to one side of the nose
• No history of nasal trauma or prior nasal surgery

Past Medical History

• Hypertension, well-controlled on lisinopril
• No history of allergies, asthma, or previous sinus infections

Drug/Medication History

• Lisinopril 10 mg daily
• Occasional use of over-the-counter decongestant nasal sprays

Social History

• Works as an office administrator
• Non-smoker, occasional social drinker
• Lives with his wife and two young children

Family History

• No known family history of chronic sinus or nasal conditions

Systems Review

• Positive for nasal congestion, no fever, chills, or facial pain/pressure
• Negative for headache, postnasal drip, cough, or changes in sense of smell/taste
• All other systems review is unremarkable

Ideas, Concerns & Expectations

• The patient is concerned that his nasal congestion may be due to a chronic sinus infection and is hoping for treatment to provide long-term relief of his symptoms.

Case Presentation

Based on the patient's history and the analysis of the key positives and negatives for the differential diagnoses, the most likely diagnosis is chronic rhinosinusitis of a non-infectious etiology, such as vasomotor or allergic rhinitis. Further evaluation with nasal endoscopy and possibly imaging would be warranted to confirm the diagnosis and rule out other structural abnormalities like nasal polyps or a deviated septum.