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DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  Jane Doe, MD

CONSULTING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Chronic rhinosinusitis.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old male who has cystic fibrosis.  He has been recently admitted due to cystic fibrosis exacerbation with gram-positive bacteremia and fevers. The patient's history is notable for recently being seen for shortness of breath and desaturation.  The patient underwent a blood culture in the emergency department showing gram-positive cocci in clusters and was subsequently admitted.  He has been on cefepime, aztreonam, voriconazole, Flonase and nasal saline.  In terms of his pulmonary complaints, his symptoms are improving and he is scheduled for a followup bronchoscopy tomorrow.  I have been asked to see him in terms of his chronic sinus complaints.  He has a history of endoscopic sinus surgery at the age of 8 and states that this immensely improved his breathing.  However, over the past year, he has developed worsening nasal congestion, facial pain and pressure over the ethmoid and infraorbital regions as well as thick green rhinorrhea.  He also has chronic cough with intermittent productive sputum and intermittent fevers and chills.  Some of this is due to his underlying pulmonary state as well.  He is chronically on Flonase and nasal saline and has been on a prolonged course of intravenous antibiotics as described.  He recently underwent a CT scan of the paranasal sinuses.

PAST MEDICAL HISTORY:  Cystic fibrosis related diabetes, pancreatic insufficiency, bipolar disorder, deep venous thrombosis in the superior vena cava, and he is chronically on Coumadin.

Past surgical history, medications, allergies, family history, social history, and review of systems per the patient's admitting history and physical.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Temperature 98.6 degrees and T-max 99.6 degrees, heart rate 104, respiratory rate 21, oxygen saturation 98% on room air, blood pressure 114/66.
GENERAL:  Age-appropriate male, in no apparent distress.  Voice is slightly hyponasal.
HEENT:  Overall, face is symmetric.  No sinus tenderness.  Facial strength intact bilaterally.  Ears:  Bilateral lobes and pinnae without deformity.  External auditory canals patent.  Tympanic membranes pearly gray, mobile and intact.  Nose:  Pale boggy mucosa.  There are some prominent small blood vessels along Kiesselbach plexus along the right anterior septum.  No active bleeding currently, although the patient has been having some intermittent epistaxis.  Anterior rhinoscopy reveals no gross evidence of masses, polyps or purulence.  Oral Cavity/Oropharynx:  Moist mucous membranes and do not show lesions.
NECK:  No palpable lymphadenopathy or thyromegaly.  Trachea is midline.
NEUROLOGIC:  Cranial nerves II through XII are grossly intact bilaterally.

PROCEDURES PERFORMED:
1.  Bilateral flexible nasal endoscopy.
2.  Cauterization of right septum.

INDICATIONS:  Epistaxis and chronic rhinosinusitis.

PROCEDURE:  We passed the flexible nasal endoscope through the right nasal cavity.  There appeared to be some prominent blood vessels along the anterior septum as described.  The middle turbinate appeared to be somewhat edematous with synechial band between the middle turbinate and lateral nasal wall that was mildly obstructing in nature.  There appeared to be polypoid disease within the ethmoid cleft as well as the maxillary sinus on the right side that was obstructing in nature.  No gross evidence of purulent rhinorrhea.  I then passed the flexible nasal endoscope through the left nasal cavity.  The left maxillary antrostomy appeared to be open itself, but there was a significant amount of mucosal thickening in the left maxillary sinus filling nearly the entire cavity.  There was also significant mucosal thickening with polypoid disease in the ethmoid itself.  There were some thick green secretions noted as well.  We then cauterized the right anterior septum using silver nitrate and there was no further evidence of bleeding.  The patient tolerated the procedure well.

CT scan of the paranasal sinuses was personally reviewed.  There were multiple abnormal findings including complete opacification of bilateral frontal sinuses.  There was evidence of prior sinus surgery with maxillary antrostomy and ethmoidectomies noted.  There was complete opacification or near complete opacification of bilateral ethmoid sinuses, particularly on the right side.  There was complete opacification of the left maxillary sinus and partial mucosal thickening of the right maxillary sinus.  There was left sphenoid sinus mucosal thickening.  The right sphenoid sinus was well aerated.  No air-fluid level throughout the paranasal sinuses.

IMPRESSION:
1.  Symptomatic chronic rhinosinusitis.
2.  Cystic fibrosis.

PLAN:  The patient has been on multiple intravenous antibiotic therapies and continues to have evidence of persistent chronic rhinosinusitis seen on flexible nasal endoscopy and CT scan of the paranasal sinuses.  Given the fact that he continues to have persistent symptoms, I do believe that he would benefit from endoscopic sinus surgery and this will be set up as an outpatient.  Otherwise, he should continue his current medications including Flonase 2 sprays each nostril once daily and nasal saline irrigations twice daily.

Thank you for allowing us to participate in this patient's care.