Acute sinusitis

Patient comes in today due to increasing sinus drainage for the last five weeks and cough. He has not been medicating himself with anything using decongestants, antihistamines or nasal sprays. He has a history of having acute infectious sinusitis that starts as a cold and has trouble resolving. He in the past has come for treatment because of sinusitis infection that lasts for multiple weeks. Today, he states he has some sinus pressure as well as blowing yellow brown mucus out of his nose and coughing it up at night. He states that he is waking up at night with coughing and is having increased postnasal drip and rhinorrhea. He states in the past we had used antibiotic treatment as well as prednisone and he has a great relief of his symptoms and his infections do not seem to recur for significant amount of time. The last time we treated him was approximately two years ago. He denies any other problems with sinus infections, upper respiratory infections or other medical conditions since last time we saw him.

ASSESSMENT:
1. Acute sinusitis.
2. Postnasal drip causing cough.
3. History of infectious sinusitis.

PLAN:
1. At this time, we will start prednisone taper 40 mg for four days, 20 mg for four days, then 10 mg for four days.
2. Start Augmentin 875 mg b.i.d. for 10 days.
3. If his symptoms resolve incompletely, we will just see him for his annual wellness checks but if he is having more complaints then he will let us know and we will see him again.

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