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CLINICAL EXAMPLE 99203
 

 
68 year old female with allergic rhinitis

CC : “Stuffy nose”

HPI: Patient states she began having increased nasal congestion about three weeks ago.  She states the problem is sometimes quite severe and is worse when she goes outside.  She is concerned she may be developing seasonal allergies.  She says the congestion is often associated with watery eyes and can last for several hours at a time.

Medications: HCTZ 12.5 mg po qd .    

PMH
: is positive for hypertension

ROS

Ears, Nose, Mouth and Throat - Negative for epistaxis, sore throat or decreased hearing
Pulmonary - Negative for cough, hemoptysis, SOB

Physical Exam

General: NAD, conversant; looks about her stated age
Vitals: 130/72, 88, 98.6
Head: NC/AT, no sinus tenderness or submandibular lymphadenopathy
Neck: Supple without lymphadenopathy; trachea midline
Eyes: anicteric sclerae with moist, pale conjunctiva and no lid lag
Nose:  normal non-injected nasal mucosa, with normal septum and turbinates
Oropharynx: No mucosal ulcerations, normal hard and soft palate.  No pharyngeal erythema
Ears: Patent external auditory canals with pearly TMs and normal hearing acuity
Lungs: CTA
CV: RRR with no MRGs
Extremities: no edema

Assessment

  1. Possible allergic rhinitis in a patient with optimally controlled HTN
Plan
  1. OTC acetaminophen and diphenhydramine
  2. Saline nasal flushes
  3. Patient was instructed to avoid decongestants with phenylpropanolamine due to the risk of exacerbating her hypertension 

For a detailed breakdown of this note with tips and advice see 99203 E/M Insight

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