ENT New Consult

Thank you for referring John Smith to me. History: Mr. Smith, a 45-year-old male, presents today with a three-week history of left-sided nasal congestion, facial pain, and a reduced sense of smell. He reports that the symptoms started gradually and have worsened over the past week. He denies any fever, cough, or sore throat. He is employed as an accountant and reports no significant exposure to irritants or allergens. His leisure activities include hiking and gardening. Treatment to date: Patient has been using over-the-counter saline nasal sprays for symptomatic relief, with minimal improvement. Past medical history: Mr. Smith has a history of seasonal allergic rhinitis, well-controlled with antihistamines. He underwent a tonsillectomy as a child. Family history is significant for a maternal history of asthma. He is a non-smoker and drinks alcohol occasionally. No known drug allergies. Medications: Cetirizine 10mg daily Allergies: No known allergies. Examination: Blood pressure 130/80 mmHg, pulse 78 bpm, respiratory rate 16 breaths/min, temperature 37.0°C. Nasal examination revealed moderate swelling and erythema of the left nasal mucosa, with purulent discharge. No polyps were visualized. The oropharynx was clear. Imaging: CT scan of the sinuses showed opacification of the left maxillary sinus, consistent with acute sinusitis. Management: Nasal swab for culture and sensitivity. Amoxicillin-clavulanate 875mg/125mg twice daily for 10 days. Instructed patient on proper nasal hygiene and saline irrigation. Follow-up appointment in two weeks. Diagnosis: Acute Left Maxillary Sinusitis Plan: Continue antibiotics as prescribed. Follow-up in two weeks for reassessment. Thank you again for including me in this patient's care.