Date: [DATE]
Patient: [PATIENT NAME]
MRN: [MEDICAL RECORD NUMBER]
Attending Physician: [DOCTOR NAME]
Subjective:
Present illness: Briefly summarize the patient’s current symptoms, including onset, duration, severity, and any progression. Focus on facial pain/pressure, nasal congestion/discharge (color, consistency), postnasal drip, cough (productive or non-productive), fever, chills, fatigue, and headache location/character.
Past medical history: Briefly mention any relevant past medical history, including allergies (seasonal, medication), history of sinusitis, upper respiratory infections (frequency), nasal polyps, or facial surgeries.
Social history: Briefly mention any pertinent social factors, such as recent travel, exposure to allergens/irritants (smoke, dust), and occupational exposures.
Objective:
Vital signs: Record current vital signs, including temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation.
Physical exam:
General: Note appearance of illness, signs of systemic infection (fever, chills).
HEENT (Head, Ears, Eyes, Nose, Throat):
Inspect nose for discharge (color, purulence), swelling, or tenderness.
Examine sinuses for tenderness with palpation (frontal, maxillary).
Look for signs of pharyngitis (redness, swelling) and postnasal drip.
Perform otoscopy to rule out otitis media (ear infection).
Neck: Assess for lymph node enlargement.
Laboratory: Consider laboratory testing selectively based on clinical presentation. Mention any tests performed and results:
Complete blood count (CBC) with differential (elevated white blood cells may suggest infection, but not always specific for bacterial sinusitis)
Imaging: Imaging is not routinely used for acute rhinosinusitis. However, if complications are suspected or symptoms persist despite treatment, mention any imaging performed (e.g., CT scan of the sinuses) and significant findings.
Assessment:
Summarize the patient’s clinical presentation, incorporating findings from history, physical exam, and laboratory/imaging studies (if applicable).
State the working diagnosis (e.g., acute bacterial rhinosinusitis) with a level of certainty (e.g., likely, possible). Consider alternative diagnoses (e.g., viral rhinosinusitis, allergic rhinitis).
Plan:
Outline the treatment plan, considering the severity of symptoms and potential for complications.
Antibiotics – If bacterial rhinosinusitis is highly suspected, specify the type, dose, and duration of antibiotics based on clinical judgment and local prescribing guidelines. Note that antibiotics are not routinely recommended for most cases of acute rhinosinusitis.
Symptomatic relief – Recommend medications for pain relief (e.g., NSAIDs), nasal decongestants (short-term use), nasal corticosteroids (for inflammation), and mucolytics (to thin mucus).
Supportive measures – Encourage increased fluid intake, use of a humidifier, and pain management strategies (warm compresses, rest).
Re-evaluation – Schedule a follow-up appointment to assess symptom improvement and response to treatment.
Note: This is a template and specific details may vary depending on the individual patient and their clinical course.