Lemonaid – Sinusitis

SLV
Video call with patient completed. Confirmed identity via name and date of birth.  

A/P: Acute bacterial sinusitis

After video eval, collection of history, and review of questionnaire, it is felt that pts s/s indicative of acute bacterial sinusitis.

Tx with first line abx appropriate for suspected bacterial sinusitis. Encouraged to use OTC antihistamine and saline nasal spray. All patient's questions answered. Encouraged to follow-up with messaging if additional questions. Understand and agrees with plan.  

Rx sent to pharmacy of pts choice.

DoseSpot reviewed. Questionnaire and PMH reviewed.

Hx of Sinusitis?: [select name="hxsinus" value="No history of sinusitis|Sinusitis 1-2 times per year|Sinusitis 2-3 times per year|Sinusitis 4 or more times per year|Sinusitis over 1 year ago"].
Recent abx use?: [select name="antibiotics" value="Antibiotic use in the last month|no antibiotic use in the last month"]. [textarea name="abxuse" default=""]
Using OTCs: Reports using [checkbox name="otc" value="no OTCs|steroid nasal saline spray|cough and cold medication|oral decongestants|oral antihistamines|Afrin nasal spray"].

Alert & oriented. No apparent distress. Pt with noted nasal voice. Has been using OTC cough and cold medication and reports this is helping mildly.

Current symptoms include: [checkbox name="symptoms" value="purulent nasal discharge|nasal obstruction|facial pain, pressure and fullness|cough|fatigue|hyposmia|anosmia|maxillary dental pain|ear fullness"]

[checkbox name="meets" value="Meets ISDA guidelines for acute bacterial sinusitis|Does NOT meet clinical guidelines for acute bacterial sinusitis"]. [checkbox name="symptomssx" value="Symptoms persistent and not improving for 10 or more days|Symptoms are severe and lasting greater than 3-4 days|Has experienced worsening or double-sickening"].