Chronic Rhinitis Evaluation Note (Allergy Clinic)

Visit Type: [new / return]; [clinic location]

Historian: [patient / parent-guardian / caregiver]; [interpreter used: language / no interpreter]

Referral Source: [referring clinician/service] – [reason for referral] (Include only if applicable.)

Records Reviewed: [sources and dates of notes/tests/questionnaires reviewed]; [records requested but unavailable] (Include only if records were reviewed at this visit.)

Chief Complaint

[Patient-stated concern capturing primary symptom(s) and burden] (Use patient's words when helpful; single concise sentence.)

History of Present Illness

[Narrative synthesis integrating:] [Symptom characterization] (Onset, duration, continuous vs episodic; nasal: congestion/obstruction, rhinorrhea vs postnasal drip, sneezing, pruritus; ocular: itch/tearing/redness; throat/ear symptoms; severity; functional impact including sleep disturbance, daytime fatigue, work/school impairment; most bothersome symptom.) [Temporal and trigger pattern] (Seasonality: seasonal/perennial/mixed with specific months if clear; environment-linked pattern: home vs work vs school, indoor vs outdoor, improvement when away; time of day; weather and irritant sensitivity; pattern with URIs.) [Exposure history guiding testing/avoidance] (Document relevant exposures only: pets/bedroom access; dust mite risks; mold/dampness indicators; pests; pollen exposures; smoke/vaping; occupational exposures with symptom pattern on days off. Focus on exposures that inform allergen selection and counseling.) [Prior treatment trials] (For each relevant agent: name, dose, duration of consistent use, adherence, technique verification for nasal sprays, clinical benefit, adverse effects. Categories as applicable: intranasal corticosteroids, oral antihistamines, intranasal antihistamines, anticholinergic nasal sprays, saline irrigation, decongestants with rebound concern, leukotriene receptor antagonists, ocular drops.) [Differential screening features] (Document features supporting phenotype: allergic—itch, sneezing paroxysms, clear rhinorrhea, seasonal/exposure-linked; nonallergic—predominant congestion, irritant/weather sensitivity, minimal itch, adult-onset; sinus disease—facial pressure/pain, hyposmia/anosmia, purulent drainage; structural—unilateral obstruction, trauma, known deviation; medication-induced—topical decongestant overuse.) [Relevant comorbidities] (Asthma symptoms, atopic dermatitis, chronic otitis/sinusitis, sleep-disordered breathing, aspirin/NSAID reactions, nasal polyp history.) [Red flags and actions] (If present: unilateral symptoms, recurrent epistaxis, severe facial pain, neurologic symptoms, vision changes, immunocompromise—document finding and action taken. If none present and clinically relevant, include pertinent negatives within narrative.)

Past Medical and Surgical History

PMH: [atopic conditions and other relevant diagnoses] (Include migraine as sinus mimic, GERD/LPR if considered contributor, pregnancy status when relevant to treatment.)

PSH: [ENT and related surgeries] (Sinus surgery, turbinate reduction, septoplasty, adenoidectomy/tonsillectomy.)

Medications

[Current rhinitis/rhinoconjunctivitis medications with dose and schedule] (Identify controller vs PRN; note technique review for nasal sprays if performed.)

[Medications impacting skin testing or procedural risk] (Document antihistamines and hold status; note beta-blockers, MAO inhibitors if applicable.)

Allergies

[Drug allergies with reaction type] (Include environmental/food allergies only if established clinical allergy with symptom-exposure correlation.)

Family History

[Atopy in first-degree relatives: allergic rhinitis, asthma, eczema] (Include only if it informs pre-test probability.)

Social History

[Housing type, pets in home, smokers at home, key occupational exposures] (Include detail sufficient to guide specific avoidance counseling.)

Review of Systems

(Focused ROS; do not duplicate HPI content. If fully addressed in HPI, state "ROS limited to HPI.")

• ENT: [nasal obstruction, rhinorrhea, postnasal drip, facial pain/pressure, smell changes]
• Eyes: [itch, tearing, redness]
• Respiratory: [cough, wheeze, dyspnea]
• Skin: [rash, eczema]
• Sleep: [snoring, apneas, sleep quality]
• GI: [reflux symptoms] (Include only if reflux is considered contributor.)

Physical Examination

(Problem-focused; include pertinent positives and negatives.)

• General: [distress level, voice quality, mouth breathing]
• Nasal: [mucosal appearance: pale/boggy vs erythematous], [turbinate hypertrophy], [discharge character], [crusting], [septal deviation], [visible polyps], [excoriation]
• Eyes: [conjunctival injection/tearing], [periorbital edema]
• Oropharynx: [cobblestoning], [postnasal drainage]
• Ears: [effusion signs] (If relevant.)
• Neck: [lymphadenopathy] (If relevant.)
• Lungs: [wheeze, cough] (If asthma considered.)
• Skin: [eczema findings] (If relevant.)

Data Reviewed

(Include this section only if external data were reviewed; otherwise omit entirely.)

• [Prior allergy testing results (skin/serum) – source, date]
• [Prior immunotherapy records – source, date]
• [Sinus imaging – report vs images reviewed, date]
• [Relevant labs (eosinophils/IgE) – date] (Only if used in reasoning.)
• [Outside clinician notes – source, date]

Testing Plan and Rationale

Clinical Impression: [suspected phenotype: allergic / nonallergic / mixed / sinus disease suspected] – [supporting exposure history and symptom pattern] (Distinguish clinical impression from confirmed diagnosis.)

Testing Plan: [skin testing to aeroallergens / serum specific IgE / no testing now] – [how results will change management: confirm suspected triggers, guide avoidance, determine immunotherapy candidacy, clarify uncertain diagnosis]. [Targeted allergen categories based on exposure and seasonality.] (Avoid indiscriminate panels.)

If testing deferred: [reason: adequate control on empiric therapy / patient preference / unable to safely hold medications / other]

Skin testing logistics: [medications and hold status], [risk considerations and plan for beta-blockers/MAO inhibitors], [patient counseling provided] (Include only if skin testing planned.)

Sinonasal evaluation escalation: [ENT referral / nasal endoscopy / sinus CT] – [indication: refractory course / red flags / diagnostic uncertainty / objective confirmation needed] (Include only if applicable.)

Assessment

(Problem-oriented list; highest clinical impact first. Include brief justification and differential reasoning when uncertainty remains.)

[Problem 1]

[Diagnosis or suspected diagnosis] – [phenotype impression if rhinitis], [key supporting features], [testing planned to clarify if applicable]

[Problem 2]

[Diagnosis or suspected diagnosis] – [brief justification and reasoning]

(Add additional problems as clinically indicated. Common categories: chronic rhinoconjunctivitis with phenotype, possible chronic rhinosinusitis, asthma/cough symptoms, medication-related issues, environmental exposure risks.)

Plan

Rhinitis Management:

• Education: [allergic vs nonallergic mechanisms, controller vs reliever expectations]
• Trigger mitigation: [measures specific to patient's exposures] (Avoid generic lists.)
• Medications: [agent, dose, route, frequency, duration]; [controller vs rescue designation]; [rationale for changes: ineffective / intolerance / nonadherence / technique issue]; [technique review if performed]
• Ocular regimen: [drops and schedule] (If conjunctivitis significant.)

Testing Plan:

• [Test modality: skin vs serum] – [rationale]
• [Targeted allergen categories]
• [Medication hold instructions] (If skin testing scheduled.)
• [Management decisions contingent on results: avoidance priorities, immunotherapy candidacy]

Sinus Disease Plan: (Include only if applicable.)

• [Initial therapy vs referral/escalation]; [indication for CT/endoscopy if ordered]
• [Return precautions: worsening facial pain, fever, vision changes, unilateral symptoms]

Immunotherapy Discussion: (Include only if discussed at this visit.)

• [Candidacy factors: persistent symptoms despite optimized medications, patient preference, sensitization/exposure correlation]
• [Risks/benefits and commitment reviewed; detailed consent per separate clinic process]

Follow-up:

• [Timing: post-testing review, after medication trial period]
• [What to track: symptoms, rescue medication use, sleep impact]
• [Return precautions] (If clinically relevant.)

(Missing Information Handling: For clinically material elements—antihistamine use before testing, unilateral symptoms, pregnancy status when relevant—document as "Unknown," "Not asked," or "Unable to obtain." Prefer omission over placeholders for non-material elements. Label clinical inferences as impressions; do not assign definitive allergic diagnosis from sensitization alone without symptom/exposure correlation; do not assume exposures or adherence/technique without verification.)