Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Chronic Sinusitis
Description: Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.
(Medical Transcription Sample Report)
HISTORY: I had the pleasure of meeting and evaluating the patient referred today for evaluation and treatment of chronic sinusitis. As you are well aware, she is a pleasant 50-year-old female who states she started having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms. She states she really has sinus problems, but this infection has been rather severe and she notes she has not had much improvement with antibiotics. She had a CT of her paranasal sinuses identifying mild mucosal thickening of right paranasal sinuses with occlusion of the ostiomeatal complex on the right and turbinate hypertrophy was also noted when I reviewed the films and there is some minimal nasal septum deviation to the left. She currently is not taking any medication for her sinuses. She also has noted that she is having some problems with her balance and possible hearing loss or at least ear popping and fullness. Her audiogram today demonstrated mild high frequency sensorineural hearing loss, normal tympanometry, and normal speech discrimination. She has tried topical nasal corticosteroid therapy without much improvement. She tried Allegra without much improvement and she believes the Allegra may have caused problems with balance to worsen. She notes her dizziness to be much worse if she does quick positional changes such as head turning or sudden movements, no ear fullness, pressure, humming, buzzing or roaring noted in her ears. She denies any previous history of sinus surgery or nasal injury. She believes she has some degree of allergy symptoms.
PAST MEDICAL HISTORY: Seasonal allergies, possible food allergies, chronic sinusitis, hypertension and history of weight change. She is currently 180 pounds.
PAST SURGICAL HISTORY: Lower extremity vein stripping, tonsillectomy and adenoidectomy.
FAMILY HISTORY: Strong for heart disease and alcoholism.
CURRENT MEDICATIONS: DynaCirc.
SOCIAL HISTORY: The patient used to smoke cigarettes for about 20 years, one-half pack a day. She currently does not, which was encouraged to continue. She rarely drinks any alcohol-containing beverages.
VITAL SIGNS: Age 50, blood pressure is 136/74, pulse 84, temperature is 98.4, weight is 180 pounds, and height is 5 feet 3 inches.
GENERAL: The patient is healthy appearing; alert and oriented to person, place and time; responds appropriately; in no acute distress.
HEAD: Normocephalic. No masses or lesions noted.
FACE: No facial tenderness or asymmetry noted.
EYES: Pupils are equal, round and reactive to light and accommodation bilaterally. Extraocular movements are intact bilaterally. No nystagmus.
NOSE: The patient appears congested. Turbinate hypertrophy is noted. There are no signs of any acute sinusitis. Septum is midline, slightly deviated to the left.
THROAT: There is clear postnasal drip. Oral hygiene is good. No masses or lesions noted. Both vocal cords move well to midline.
NECK: The neck is supple with no adenopathy or masses palpated. The trachea is midline. The thyroid gland is of normal size with no nodules.
LUNGS: Clear to auscultation bilaterally. No wheeze noted.
HEART: Regular rate and rhythm. No murmur noted.
NEUROLOGIC: Facial nerve is intact bilaterally. The remaining cranial nerves are intact without focal deficit.
PROCEDURE: Fiberoptic nasopharyngoscopy identifying turbinate hypertrophy and nasal septum deviation to the left, more significant posteriorly.
1. Probable increasing problems with allergic rhinitis and chronic sinusitis, both contributing to the patient's symptoms.
2. Subjective dizziness, etiology uncertain; however, consider positional vertigo versus vestibular neuronitis as possible ear causes of dizziness, cannot rule out systemic, central or medication or causes at this time.
3. Inferior turbinate hypertrophy.
4. Nasal septum deformity.
RECOMMENDATIONS: An ENG was ordered to evaluate vestibular function. She was placed on Veramyst nasal spray two sprays each nostril daily and even twice daily if symptoms are worsening. A Medrol Dosepak was prescribed as directed. The patient was given instruction on use of nasal saline irrigation to be used twice daily and Clarinex 5 mg daily was recommended. After the patients' ENG examination, we will see the patient back for further evaluation and treatment recommendations. In light of the patient's atypical dizziness symptoms, I cannot rule out other pathology at this time, and I informed her if there are any acute changes or problems with regards to her balance or any other acute changes, which she attributes associated with her dizziness, she most likely should pursue an emergent visit to the emergency room.
Thank you for allowing me to participate with the care of your patient.
Keywords: consult - history and phy., nasal congestion, facial discomfort, mucosal thickening, allergic rhinitis, chronic sinusitis, nasal septum deformity, eng, vestibular function, nasal septum deviation, postnasal drip, nasal septum, turbinate hypertrophy, turbinate, hypertrophy, infection, ear, dizziness, sinusitis, nasal,