Skip to content
MedicalCoreCoding

Try a topic like assisted living, critical care or a code like 99214.

AboutContact

National Colony, Aurangabad, 431001 · Mon - Fri: 9am - 5pm

Report #29 · Office & outpatient

Facial pain for 10 days

5 questionsCOPADataRiskMDMCode

From the lesson Office & Outpatient

Jump to the questions

Clinical note · #29

Office & outpatient

Patient: Sarah Collins

Age: 46

Place of Service: Office – Outpatient

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

History of Present Illness (HPI):

The patient presents for evaluation of persistent and worsening nasal congestion, sinus pressure, thick nasal discharge, and facial pain for approximately ten days. Symptoms initially began as mild congestion but have progressively worsened despite the use of over-the-counter decongestants and saline nasal spray, which have provided minimal relief. She reports persistent fever at home with temperatures up to 101.3°F, associated with chills, generalized fatigue, and malaise. These symptoms have resulted in decreased oral intake and difficulty performing usual daily activities. She also reports frontal headache and postnasal drip. She denies shortness of breath, chest pain, nausea, vomiting, visual changes, focal neurologic deficits, or syncope. No recent antibiotic use is reported.

Review of Systems (ROS):

  • ENT: Nasal congestion, purulent nasal discharge, facial pressure
  • Constitutional: Fever, chills, fatigue, malaise
  • Neurologic: Frontal headache
  • Respiratory: Denies cough or shortness of breath
  • Gastrointestinal: Denies nausea or vomiting
  • All other systems reviewed and negative

Past Medical History (PMH):

  • Seasonal allergic rhinitis

Medications: None

Allergies: No known drug allergies

Physical Examination:

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

Diagnostic Data:

  • COVID-19 antigen test ordered and reviewed – negative
  • Rapid influenza A/B test ordered and reviewed – negative

Assessment:

Acute bacterial sinusitis with systemic symptoms.

Plan:

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