Clinical note · #33
Office & outpatient
Patient: Anna Lopez
Age: 29
Place of Service: Office – Outpatient
Patient Status: New Patient
Chief Complaint: Seasonal allergy symptoms.
HPI: The patient presents with mild nasal congestion, sneezing, and clear nasal discharge for five days. Symptoms are stable and mild. She denies fever, headache, facial pain, cough, shortness of breath, or systemic symptoms. Partial relief noted with OTC saline spray.
ROS:
- ENT: Mild congestion and sneezing
- Eyes: Occasional itching
- Constitutional: Denies fever or fatigue
PMH: None
Medications: None
Allergies: NKDA
Physical Exam:
- General: No distress
- HEENT: Mild boggy nasal mucosa
- Lungs: Clear
Assessment: Mild seasonal allergic rhinitis.
Plan:
- Continue OTC saline spray
- Avoid allergens
- No prescription medications