Sinus template

We were pleased to see this patient today. ID: 45 year old male **Subjective:** Reason for Referral: Chronic sinusitis with nasal obstruction History of Present Illness: The patient reports a 6-month history of nasal congestion, facial pressure, and postnasal drip. Symptoms have worsened over the past month, with occasional headaches. Relevant Past Medical History: - Asthma: Yes - Environmental Allergy: Tested (Positive for dust mites) - ASA Sensitivity: No - Previous Sinonasal Surgery: Yes (Surgery Date: 15 March 2020) Medications: Fluticasone nasal spray, Montelukast Medication Allergies: No known drug allergies Social History: - Smoking: Ex-smoker (10 pack-year history) - Alcohol: Social **Objective:** Physical Examination: - Ears: EACs and TMs within normal limits - Oral Cavity: Within normal limits - Oropharynx: Within normal limits - Septum: Deviation to right - Flexible Endoscopy: - Polyps: Right Grade: 2, Left Grade: 1 - Mucosa: Moderate Inflammation - Purulence: Yes - Nasopharynx: Normal - Larynx: Normal, mobile vocal cords - Hypopharynx: Normal, no lesions seen - Other Comments: Mild crusting observed - Neck: No cervical adenopathy The remainder of the head and neck examination was unremarkable. Investigations: - Imaging: CT - Region: Sinus **Assessment:** Summary: The patient presents with chronic sinusitis with nasal polyps and moderate inflammation, likely exacerbated by environmental allergies and a history of asthma. **Plan:** We have recommended bilateral endoscopic sinus surgery with possible septoplasty. The benefits, risks—including risks of general anesthesia, infection, bleeding, <1% risk of eye/brain injury, septal perforation, and potential need for revision surgery—were discussed. Surgery is scheduled for the next available date. Thank you for asking us to see this patient. Please let us know if you have any questions. Sincerely, Dr. John Smith for Consultant Dr. Thomas Kelly