Worsening sinus pressure

Patient: Sarah Collins

Age: 46

Place of Service: Office – Outpatient

Chief Complaint: Worsening sinus pressure and nasal congestion for 10 days.

History of Present Illness (HPI):

The patient presents for evaluation of persistent sinus congestion, facial pressure, and thick nasal discharge for the past ten days. Symptoms initially started mild but have progressively worsened. She reports facial pain and pressure, especially when bending forward. She denies shortness of breath, chest pain, nausea, or vomiting. She reports low-grade fevers at home. Over-the-counter decongestants provided minimal relief. No recent antibiotic use.

Review of Systems (ROS):

• ENT: Sinus pressure, purulent nasal discharge
• Constitutional: Reports low-grade fever
• Respiratory: Denies cough or shortness of breath
• All other systems reviewed and negative

Past Medical History (PMH):

• Seasonal allergic rhinitis

Medications: None

Allergies: No known drug allergies

Physical Examination:

• General: Alert, appears uncomfortable but in no acute distress
• HEENT: Maxillary sinus tenderness; purulent nasal discharge noted
• Lungs: Clear to auscultation bilaterally
• Heart: Regular rate and rhythm

Assessment:

Acute bacterial sinusitis.

Plan:

• Symptoms and findings discussed with the patient
• Start amoxicillin-clavulanate 875/125 mg orally twice daily for 7 days
• Continue saline nasal spray and hydration
• Acetaminophen as needed for facial pain or fever
• Return precautions discussed