Chief Complaint: “I have sinus pressure and congestion” x 10 days
HPI: 34 y/o male patient with no significant PMH presents to urgent care complaining of sinus pressure, nasal congestion and sore throat x 10 days. States the severity of the sinus pressure is a 6.5/10 and states he has felt similar symptoms in the past and was diagnosed with a sinus infection. Patient has noticed thick greenish drainage from his nose. Admits that the sore throat, 1/10 pain, is better and is able to tolerate foods/liquids normally. Has tried over the counter Sudafed, with slight relief of symptoms. Denies fever, chills, cough, chest pain, SOB, dizziness, headache, ear pain, N/V/D.
PMH:
None.
Per patient: Up to date on all immunizations.
Past Hospitalizations:
None.
Past Surgeries:
None.
Medications:
None.
Allergies:
No known drug, food, environmental allergies.
Family History:
Mother – alive and well
Father – alive and well
Social History:
- Smoking: non-smoker
- Substance use: denies alcohol or drug use
- Caffeine: denies caffeine use
- Occupational history: unemployed
- Home situation: lives in apartment with husband
Review of Systems:
General: Denies fever, chills, fatigue, weakness, or change of appetite.
Skin: Denies any signs of discoloration, any new rashes, or any changes in skin.
Head: Denies headache, dizziness, any recent head trauma.
Eyes: Denies any changes in vision, blurry vision, swelling, or discharge.
Ears: Denies pain or discharge.
Nose/Sinuses: Admits to discharge, congestion, and sinus pressure. Denies swelling or epistaxis
Mouth/Throat: Admits to sore throat. Denies dysphagia or hoaseness.
Neck: Denies swollen glands.
Pulmonary System: Denies coughing, SOB or wheezing. Denies DOE, hemoptysis or cyanosis.
Cardiovascular System: Denies chest pain, palpitations, edema.
Gastrointestinal System: Denies changes in stool, hemorrhoids, constipation, rectal bleeding. diarrhea, or loss of appetite.
Genitourinary System: Denies urinary frequency, oliguria, nocturia, or incontinence.
Nervous: Denies changes in mental status.
Physical:
General: Well nourished male in no apparent distress, alert and active. Dressed appropriately for the weather.
Vitals:
- BP: 118/76 (seated, right arm)
- HR: 72 BPM (regular)
- RR: 18/min (unlabored)
- T: 97.6 F (oral)
- O2: 99% (room air)
Hair, Skin, Nails:
Hair: Average quantity and distribution. Black color. Straight texture. No signs of lice or dandruff.
Skin: Warm and moist, smooth texture, good turgor. No discoloration or scarring.
Nails: No clubbing, or signs of infection. Capillary refill <2 seconds in upper extremities.
Eyes: No erythema or edema, No discharge present. No pain with EOM and not warm to touch. No strabismus, exophthalmos, or ptosis. Sclera white, cornea clear, conjunctiva pink. Pupils are equal, round, and reactive to light. EOMs intact with no nystagmus.
Nose: Erythema noted in B/L turbinates. Mucopurulent discharge noted. No signs of trauma or deformities.
Sinuses: Tenderness to palpation over bilateral maxillary and ethmoid sinuses. No tenderness over frontal sinuses.
Ears: External ears with no masses, lesions, or discharge. B/L TMs pearly gray, intact with light reflex in good position.
Mouth: Lips pink and moist with no cyanosis or lesions. Buccal mucosa, palate, and gingivae are pink and well hydrated. No masses or lesions. Normal dentition, with no signs of dental caries. Tonsils present with no signs of exudate. Uvula midline with no edema or lesions.
Throat: No signs of erythema or swelling. No exudates or lesions visualized. Uvula midline.
Neck: Trachea midline. No masses, lesions, scars, pulsations. Supple and nontender to palpation. No cervical lymphadenopathy. Thyroid non tender to palpation.
Lungs:
Clear to auscultation. Chest was symmetrical with no signs of labored breathing.
Heart:
Regular rate and rhythm. Distinct S1/S2 with no murmurs, splitting, friction rubs, or S3/S4.
Neuro: Alert and Oriented.
Differential Diagnosis:
- Acute sinusitis (Bacterial)
- Pharyngitis
- COVID-19
- Influenza
- Upper respiratory infection
Assessment:
34 y/o male pt presenting with sinus pressure and nasal congestion with green drainage x 10 days. PE is significant for tenderness over B/L maxillary and ethmoid sinuses and erythema in bilateral turbinates. Lungs are clear to auscultation bilaterally. Will wait on results of rapid COVID, strep, and influenza and if negative treat for acute sinusitis.
Tests ran at office:
- Rapid Strep – negative
- Rapid COVID – negative
- Rapid Influenza A/B – negative
Plan/Patient Education:
- Amoxicillin – Clavulanate 875-125 mg 1 tab BID x 10 days
- OTC Tylenol/ibuprofen as needed for pain
- Use humidifier at home to help break up mucus
- Go to ER if worsening symptoms (fever, intractable facial pain, unable to tolerate foods/liquids) or follow up with PCP if symptoms are not improving with treatment
