Nursing Homework week 6

40-year-old female Hispanic with congestion, facial pain, postnasal drip, and frontal headache for 10 days. Thick yellow nasal discharge and mild fatigue. No fever, sore throat, or cough denied. No allergies or chronic sinus disease. Physical exam: erythematous and swollen nasal mucosa, tender over maxillary sinuses, mildly erythematous throat, clear lungs. Vitals stable and afebrile. Assessment consistent with acute bacterial sinusitis. Treated with amoxicillin-clavulanate 875/125 mg PO BID for 7 days, saline nasal spray PRN, hydration, and warm compresses. Instructed to complete antibiotics, monitor for worsening symptoms, and follow up if no improvement in 7–10 days. Patient verbalized understanding and agreement with plan.

· Type of Visit: New Consult

· Reason for Visit: Nasal congestion, facial pressure, and headache

· Chief Complaint: “I’ve had sinus pressure, stuffy nose, and a headache for over a week.”

· Type of H&P: Problem-focused

· Time with Patient: 25 minutes

· Consult with Preceptor: 10 minutes

· Decision-Making Type: Low to moderate complexity

Clinical Notes:

40-year-old Hispanic female presents with nasal congestion, facial pain, postnasal drip, and frontal headache for 10 days. Reports thick yellow nasal discharge and mild fatigue. Denies fever, sore throat, or cough. No history of chronic sinus disease or allergies. Physical exam: nasal mucosa erythematous and swollen, tenderness over maxillary sinuses, throat mildly erythematous, lungs clear. Vitals stable and afebrile. Assessment consistent with acute bacterial sinusitis. Treatment initiated with amoxicillin-clavulanate 875/125 mg PO twice daily for 7 days, saline nasal spray as needed, hydration, and warm compresses. Advised to complete antibiotics, monitor for worsening symptoms, and follow up if not improved in 7–10 days. Patient verbalized understanding and agreement with plan.

Social Problems Addressed:

☑ Prevention ☑ Safety ☑ Nutrition/Exercise

ICD-10 Diagnosis Codes:

1. J01.00 – Acute maxillary sinusitis, unspecified

2. R51.9 – Headache, unspecified

CPT® Billing Codes:

1. 99213 – Office or other outpatient visit for the evaluation and management of an established patient, low to moderate complexity

2. 87880 – Infectious agent antigen detection by immunoassay (rapid strep test, if performed to rule out pharyngitis)

Medications:

· New/Refilled Rx this visit:

· Amoxicillin-clavulanate 875/125 mg PO twice daily for 7 days

· Fluticasone nasal spray, 1 spray each nostril daily PRN congestion

· OTC Drugs: Saline nasal spray, acetaminophen as needed

Adherence Issues with Medications:

☑ Knowledge deficit (education on completing antibiotics)

Procedures/Skills Observed/Performed:

☑ Physical Assessment ☑ ENT Exam ☑ Patient Education/Counseling