Clinician Specialty: Otorhinolaryngologist (ENT Specialist)
Patient Visit Note
Chief Complaint
• Visit for: Chronic Sinusitis
History of Present Illness
Patient's age and gender is a 45 year old female.
• Allergy list reviewed
• Medication list reviewed
Presenting symptoms include a 6-month history of facial pressure, nasal congestion, and post-nasal drip. Symptoms are worse in the morning and have been persistent despite over-the-counter remedies.
The main symptoms of Chronic Sinusitis include:
• Facial pressure (primarily frontal and maxillary)
• Nasal congestion (bilateral)
• Post-nasal drip (thick, clear mucus)
Previous treatments include: Saline nasal rinses, decongestants (pseudoephedrine), and a course of amoxicillin for a presumed sinus infection 2 months prior with temporary improvement.
Previous antibiotics include: Amoxicillin (250 mg TID for 10 days).
Previous medical testing includes: Sinus X-ray 3 months ago, reported as showing mucosal thickening in maxillary sinuses.
Patient reports occasional mild headaches associated with the facial pressure and some fatigue. Denies fever, chills, vision changes, or ear pain.
Current Medication
• Fexofenadine 180mg, daily, 2 refills
• Fluticasone nasal spray, 2 sprays each nostril daily, 1 refill
Past Medical/Surgical History
Reported:
• Appendectomy (age 12)
• Allergic rhinitis
Social History
Tobacco use: Denies current tobacco use. Former smoker (5 pack-years), quit 10 years ago.
Alcohol: Occasional social use (1-2 drinks per week).
Drug Use: Denies illicit drug use.
Work: Office administrator, works full-time.
Allergies
• Penicillin (hives)
• Dust mites (allergic rhinitis symptoms)
Review of Systems
Systemic: Denies fever, chills, weight changes. Reports mild fatigue.
Neck: Denies pain, stiffness, or masses.
Eyes: Denies vision changes, diplopia, or discharge.
Otolaryngology: Reports nasal congestion, facial pressure, post-nasal drip. Denies ear pain, tinnitus, or hearing loss.
Pulmonary: Denies cough, shortness of breath, or wheezing.
Endocrine: Denies polyuria, polydipsia, or heat/cold intolerance.
Hematologic: Denies easy bruising or bleeding.
Musculoskeletal: Denies joint pain or muscle aches.
Neurological: Denies numbness, tingling, or weakness. Reports occasional mild headaches.
Psychological: Denies anxiety, depression, or sleep disturbance.
Skin: Denies rashes or lesions.
Physical Findings
• Vitals taken 1 November 2024 at 10:30 AM:
Pulse Rate-Sitting: 72 bpm
Temp-Temporal: 36.8°C
Height: 165 cm
Weight: 70 kg
Body Mass Index: 25.7 kg/m²
Body Surface Area: 1.8 m²
Oxygen Saturation: 98 %
General Appearance
General: Well-nourished, well-developed female in no acute distress.
Head
Head: Normocephalic, atraumatic.
Face: Mild tenderness to palpation over frontal and maxillary sinuses.
Facial strength: Symmetrical, intact.
Sinuses: Mildly tender to palpation over bilateral maxillary and frontal sinuses.
Neck
Global Assessment: Supple, full range of motion, no thyromegaly.
Salivary Glands: Non-palpable, non-tender.
Submandibular Glands: Non-palpable.
Parotid Glands: Non-palpable.
Trachea: Midline.
Thyroid: Not enlarged, non-tender.
Eyes
Eye Movement: Full extraocular movements (EOMs) intact.
Gaze: Steady, no nystagmus.
Ears
External Ear: Symmetrical, no lesions or discharge.
External Auditory Canal: Clear, no erythema or oedema.
Tympanic Membrane: Intact, pearly grey, good light reflex bilaterally.
Assessment of Hearing: Grossly intact to whispered voice bilaterally.
Nose
External Inspection of the Nose: No external deformities or lesions.
Nasal Mucosa: Erythematous and boggy bilaterally.
Septum: Midline, no deviation or perforation.
Turbinates: Enlarged, pale, and boggy inferior turbinates bilaterally.
Middle Meatus: Minimal clear discharge noted bilaterally.
Oral Cavity
Lips: Moist, pink, no lesions.
Teeth: Good dentition, no gross decay.
Gingiva: Pink, no inflammation.
Oral Mucosa: Pink, moist, no lesions.
Palate: Hard and soft palates intact.
Tongue: Midline, no lesions.
Floor of Mouth: Clear.
Tonsils: Present, small, no exudates or erythema.
Base of Tongue: Not visualised fully.
Pharyngeal Walls: Mild post-nasal drip noted, no erythema or exudates.
Larynx
Larynx: Not directly visualised during this exam.
Nasopharynx: Mild oedema, clear mucoid discharge.
Lymph Nodes
Cervical lymph nodes: No cervical lymphadenopathy palpable.
Lungs
Inspection: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi.
Cardiovascular
Inspection: Regular rate and rhythm, no murmurs, gallops, or rubs.
Neurological
Mental Status: Alert and oriented to person, place, and time.
Mood/Affect: Euthymic, appropriate.
Cranial Nerves: II-XII grossly intact.
Speech: Clear, fluent.
Voice: Normal quality.
Assessment
• J32.9 - Chronic sinusitis, unspecified
• J30.1 - Allergic rhinitis due to pollen
Counselling/Education
• Discussed chronic nature of sinusitis and importance of long-term management.
• Reviewed proper technique for nasal saline rinses and steroid sprays.
Plan
Discussed initiating a 3-week course of Augmentin 875mg twice daily and continuing fluticasone nasal spray daily. Advised patient to follow up in 4 weeks for reassessment and consideration of sinus CT if symptoms persist.
• Prescribed Augmentin 875mg BID for 3 weeks.
• Continue Fluticasone nasal spray daily.
• Schedule follow-up appointment in 4 weeks.
Interpretation
Previous sinus X-ray showed mucosal thickening, consistent with a chronic inflammatory process. Physical exam findings of boggy nasal mucosa and turbinates support the diagnosis of chronic rhinosinusitis.
Scribe note:
"I, Jane Smith, acted as a scribe during this office visit. I was present in the office during the examination and acted to document the findings into the EHR. I was acting directly under the supervision of Dr. Thomas Kelly."
Patient Visit Note
Chief Complaint
• Visit for: [chief complaint]
History of Present Illness
[Patient's age and gender] is a [age] year old [gender].
• Allergy list reviewed
• Medication list reviewed
[Presenting symptoms and duration] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
The main symptoms of [chief complaint] include:
• [Symptom 1] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• [Symptom 2] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• [Symptom 3] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Previous treatments include: [List any treatments the patient has tried] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Previous antibiotics include: [Mention if applicable] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Previous medical testing includes: [List relevant diagnostic tests] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Additional relevant history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Current Medication
• [Medication name, dose, frequency, refills] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• [Medication name, dose, frequency, refills] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Past Medical/Surgical History
Reported:
• [Surgery or condition 1] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• [Surgery or condition 2] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Social History
Tobacco use: [Tobacco use history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Alcohol: [Alcohol use history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Drug Use: [Drug use history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Work: [Employment status or occupation, including informal or grant-based income sources if noted] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Allergies
• [Allergen 1] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• [Allergen 2] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Review of Systems
Systemic: [General symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Neck: [Neck complaints] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Eyes: [Vision issues] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Otolaryngology: [ENT-related symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Pulmonary: [Lung-related symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Endocrine: [Hormonal/gland-related symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Hematologic: [Bleeding/bruising tendencies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Musculoskeletal: [Joint/muscle complaints] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Neurological: [Neurological symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Psychological: [Mental health symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Skin: [Skin-related symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Physical Findings
• Vitals taken [date and time]:
Pulse Rate-Sitting: [pulse rate] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Temp-Temporal: [temperature] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Height: [height in cm] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Weight: [weight in kg] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Body Mass Index: [BMI] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Body Surface Area: [BSA] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Oxygen Saturation: [oxygen saturation in %] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
General Appearance
General: [General appearance] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Head
Head: [Head findings]
Face: [Facial findings]
Facial strength: [Facial strength]
Sinuses: [Sinus findings]
(Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit each item completely.)
Neck
Global Assessment: [Neck findings]
Salivary Glands: [Salivary gland findings]
Submandibular Glands: [Submandibular gland findings]
Parotid Glands: [Parotid gland findings]
Trachea: [Trachea position]
Thyroid: [Thyroid findings]
(Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit each item completely.)
Eyes
Eye Movement: [Eye movement findings]
Gaze: [Gaze findings]
(Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit each item completely.)
Ears
External Ear: [External ear findings]
External Auditory Canal: [Auditory canal findings]
Tympanic Membrane: [Tympanic membrane findings]
Assessment of Hearing: [Hearing assessment]
(Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit each item completely.)
Nose
External Inspection of the Nose: [Nose inspection findings]
Nasal Mucosa: [Nasal mucosa findings]
Septum: [Septum findings]
Turbinates: [Turbinates findings]
Middle Meatus: [Middle meatus findings]
(Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit each item completely.)
Oral Cavity
Lips: [Lip findings]
Teeth: [Dentition]
Gingiva: [Gum findings]
Oral Mucosa: [Oral mucosa findings]
Palate: [Palate findings]
Tongue: [Tongue findings]
Floor of Mouth: [Floor findings]
Tonsils: [Tonsil status]
Base of Tongue: [Base of tongue]
Pharyngeal Walls: [Pharyngeal findings]
(Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit each item completely.)
Larynx
Larynx: [Larynx findings]
Nasopharynx: [Nasopharynx findings]
(Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit each item completely.)
Lymph Nodes
Cervical lymph nodes: [Lymph node findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Lungs
Inspection: [Lung findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Cardiovascular
Inspection: [Cardiovascular findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Neurological
Mental Status: [Mental status]
Mood/Affect: [Mood and affect]
Cranial Nerves: [Cranial nerve exam]
Speech: [Speech quality]
Voice: [Voice quality]
(Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit each item completely.)
Assessment
• [Diagnosis code and description]
• [Diagnosis code and description]
(Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Counselling/Education
• [Counselling topic 1]
• [Counselling topic 2]
(Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit each item completely.)
Plan
[Full sentence description of treatment plan, medications, and follow-up instructions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
• [Instruction 1]
• [Instruction 2]
(Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit each item completely.)
Interpretation
[Summary of test results and interpretation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Procedure
[Procedure name]
Indication: [Procedure indication]
Location: [Procedure location]
[Procedure-specific findings]: [Describe findings]
Procedure note: [Procedure summary and response]
(Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit each item completely.)
Scribe note:
"I, [scribe name], acted as a scribe during this office visit. I was present in the office during the examination and acted to document the findings into the EHR. I was acting directly under the supervision of Dr. [supervising doctor’s name]."
(For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)
