Example Letter

# Chief Complaint
Sinus pain and purulent nasal discharge x 11 days.

# Age and Sex
38-year-old female.

# History of Present Illness
Symptoms began 11 days ago as a typical viral upper respiratory infection: clear rhinorrhea, mild sore throat, low-grade fevers (~99.5°F), and fatigue. By days 5-6 I felt nearly back to baseline. On day 7, symptoms worsened sharply: new onset of thick yellow-green purulent nasal discharge, severe right-sided maxillary facial pressure and pain that is worse when I bend forward, a new fever to 102.4°F, and a frontal headache. Over the past 4 days symptoms have not improved despite saline nasal irrigation, pseudoephedrine 30 mg q6h, and ibuprofen 400 mg q6h. Persistent foul taste from postnasal drip. No improvement at any point since the day 7 worsening.

# Review of Systems
- Constitutional: Positive for fevers up to 102.4°F and fatigue
- HEENT: Positive for purulent yellow-green nasal discharge, right > left maxillary facial pain worsened by bending forward, frontal headache, postnasal drip with foul taste, mild residual sore throat
- Respiratory: Mild productive cough with clear sputum (from postnasal drip). Denies shortness of breath, chest pain, or wheezing
- Eyes: Denies periorbital swelling, periorbital erythema, vision changes, or diplopia
- Neuro: Denies neck stiffness, photophobia, altered mental status, or focal deficits
- ENT: Denies ear pain or hearing changes
- GI: Denies nausea, vomiting, or diarrhea

# Past Medical History
No chronic sinus disease. No prior sinus surgery or nasal polyps. No asthma. No immunocompromise. No prior antibiotic use in the past 6 weeks. No current medications other than the OTC trial above.

# Allergies
NKDA. No history of penicillin or beta-lactam allergy. No food allergies.

# Family History
Mother: seasonal allergies, hypertension. Father: healthy. No family history of immunodeficiency, chronic sinusitis, or nasal polyps.

# Social History
Lives with spouse and two young children (both had viral URIs in the past 2 weeks). Office worker (remote). Non-smoker, no vaping. Occasional social alcohol use. No recent travel. No known sick contacts outside the household.

# What I Think It Might Be
Acute bacterial rhinosinusitis. My presentation meets IDSA 2012 criteria for ABRS on two of the three accepted clinical presentations: (1) persistent symptoms lasting ≥10 days without evidence of clinical improvement, and (2) "double-sickening" — new fever, worsened nasal discharge, and facial pain following a viral URI that was initially improving. Reference: Chow AW, et al. IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults. Clin Infect Dis. 2012;54(8):e72-e112.

# What I Am Hoping For
A 5-7 day course of amoxicillin-clavulanate, per the IDSA first-line recommendation for adults with acute bacterial rhinosinusitis (ABRS).