ENT New Patient Note

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."