Nasal congestion and facial pressure

Patient: Michael Reed

Age: 41

Place of Service: Office – Outpatient

Chief Complaint: Nasal congestion and facial pressure for 5 days.

History of Present Illness (HPI):

The patient presents for evaluation of nasal congestion, sinus pressure, and mild headache for the past five days. Symptoms developed gradually and have remained stable. He reports clear nasal discharge and facial fullness, worse in the mornings. He denies fever, chills, severe facial pain, purulent nasal discharge, cough, shortness of breath, chest pain, nausea, or vomiting. He has used saline nasal spray with mild relief. No recent antibiotic use. No known sick contacts.

Review of Systems (ROS):

• ENT: Nasal congestion, sinus pressure
• Respiratory: Denies cough or shortness of breath
• Constitutional: Denies fever or chills
• Neurologic: Mild headache
• All other systems reviewed and negative

Past Medical History (PMH):

• No chronic medical conditions reported

Medications: None

Allergies: No known drug allergies

Physical Examination:

• General: Alert, oriented, no acute distress
• HEENT: Nasal mucosa congested; mild maxillary sinus tenderness; no purulent discharge
• Lungs: Clear to auscultation bilaterally
• Heart: Regular rate and rhythm

Assessment:

Acute sinus symptoms, likely viral in etiology.

Plan:

• Symptoms discussed and findings reviewed with the patient
• No antibiotics indicated at this time
• Supportive care with saline nasal spray, hydration, and rest
• Over-the-counter acetaminophen or ibuprofen as needed for headache or facial discomfort
• Return precautions discussed if symptoms worsen or persist beyond 10 days