ENT Follow up

I had the pleasure of seeing Sarah in follow up today. History: Patient returns today for a follow up appointment regarding her chronic sinusitis. She reports persistent nasal congestion, facial pressure, and headaches, despite previous treatment with antibiotics and nasal corticosteroids. She denies any new symptoms or worsening of existing ones. She is employed as a teacher and enjoys gardening in her free time. Her husband was in attendance with her. Examination: Vital signs: Blood pressure 120/80 mmHg, pulse 78 bpm, respirations 16 breaths/min, temperature 37.0°C. Physical examination: Anterior rhinoscopy revealed moderate swelling and inflammation of the nasal mucosa bilaterally, with purulent discharge present. No polyps were visualized. The oropharynx was clear. Ears and neck were unremarkable. Management: Investigations planned: A CT scan of the sinuses was ordered to assess for any structural abnormalities or complications. Treatment planned: Continue nasal corticosteroid spray twice daily. Prescribed a course of oral antibiotics (amoxicillin-clavulanate) for 14 days. Advised on saline nasal rinses. Relevant other actions: Provided patient education on sinus infection management and potential complications. Scheduled a follow-up appointment in 4 weeks. Diagnosis: Chronic sinusitis. Plan: Continue current treatment plan and follow up in 4 weeks. Review CT scan results and adjust treatment as needed. Thank you again for including me in this patient's care.