Family Medicine Note

SUBJECTIVE

• 52 yo M (Thomas Vance, DOB: 12/08/1971, MRN: 492-810-33) presents for acute visit c/o 5-day hx of facial pain and nasal congestion. Describes symptom as "heavy pressure behind my cheeks and a throbbing toothache." Reports thick purulent rhinorrhea, worse when bending forward. Tried OTC pseudoephedrine (Sudafed®) and saline nasal rinses with minimal relief. Not previously seen elsewhere for this episode. Also requests routine f/u for HTN and T2DM.

Relevant Past Medical History

• PMH: Essential HTN, T2DM. PSH: Laparoscopic cholecystectomy (2015).
• Medications: lisinopril (Zestril®) 20 mg PO daily, metformin (Glucophage®) 1,000 mg PO BID.
• Social history: Never smoker, ETOH 1–2 beers/week, works as an accountant.
• Allergies: Penicillin (urticaria).

REVIEW OF SYSTEMS

• Constitutional symptoms: Low-grade fever (37.9 °C at home), mild fatigue. Denies chills, night sweats, weight change.
• Eyes: Denies pain, redness, discharge, vision changes.
• Ears, Nose, Mouth, Throat: Positive for nasal congestion, maxillary sinus pain, purulent rhinorrhea, mild sore throat from post-nasal drip. Denies ear pain, hearing changes, dysphagia.
• Cardiovascular: Denies chest pain, SOB, PND, orthopnea, edema, palpitations.
• Respiratory: Occasional dry cough (worse at night). Denies sputum, wheezing, dyspnea.
• Gastrointestinal: Denies N/V/D, constipation, abdominal pain, heartburn, melena.
• Genitourinary: Denies dysuria, frequency, hematuria, urgency, flank pain.
• Musculoskeletal: Denies arthralgias, myalgias, back pain, neck stiffness.
• Integumentary (Skin): Denies rash, lesions, pruritus.
• Neurological: Mild frontal headache. Denies weakness, numbness, dizziness, syncope.
• Psychiatric: Denies anxiety, depression, insomnia, SI/HI.
• Endocrine: Denies polyuria, polydipsia, heat/cold intolerance.
• Hematologic/Lymphatic: Denies easy bruising, bleeding, lymphadenopathy.
• Allergic/Immunologic: Hx of seasonal allergic rhinitis. Denies autoimmune disorders.

OBJECTIVE

• Vitals (10:15 America/Chicago): BP 138/84 mmHg, HR 78 bpm, RR 14/min, Temp 37.6 °C, SpO2 98 % RA, Wt 88.5 kg, BMI 27.8 kg/m². Gen: Alert, NAD. HEENT: PERRLA, TMs clear bilaterally. Nasal mucosa erythematous and edematous with purulent discharge in middle meatus bilaterally. TTP over bilateral maxillary sinuses. Oropharynx with mild posterior pharyngeal cobblestoning and mucopurulent drainage; no tonsillar exudates. Neck: Supple, mild tender anterior cervical lymphadenopathy. CV: RRR, S1/S2 normal, no murmurs. Resp: CTAB, no wheezes or rales. Monofilament foot exam: Intact sensation bilaterally, pedal pulses 2+.
• POC HbA1c: 6.9 %. POC Urinalysis: Negative for protein, glucose, leukocytes, nitrites.

ASSESSMENT & PLAN

1. Acute maxillary sinusitis, J01.00

• Acute bacterial rhinosinusitis
• Viral URI, allergic rhinitis, odontogenic infection
• None indicated at this time
• doxycycline (Vibramycin®) 100 mg PO BID x 5 days; fluticasone propionate (Flonase®) 50 mcg/actuation nasal spray 2 sprays each nostril daily; paracetamol (acetaminophen, Tylenol®) 500 mg PO Q6H PRN pain/fever; continue saline sinus rinses
• None
• None

2. Essential hypertension, I10

• Essential hypertension
• White coat hypertension
• BMP to check baseline renal function and electrolytes
• Continue lisinopril (Zestril®) 20 mg PO daily; encourage low-sodium diet and home BP monitoring
• None
• 80048 (Basic metabolic panel)

3. Type 2 diabetes mellitus without complications, E11.9

• Type 2 diabetes mellitus
• None
• Fasting lipid panel and urine microalbumin/creatinine ratio ordered for next routine visit
• Continue metformin (Glucophage®) 1,000 mg PO BID; glycemic control at goal
• Annual ophthalmology referral for dilated diabetic eye exam
• 83036 (Hemoglobin A1c)

Visit CPT code (for the level and type of visit; record it as a first visit unless another status is explicitly stated in the information you have been provided with): 99204

Sarah Jenkins, MD

Family Medicine

Oakwood Family Practice

24/05/2024