How do you document nasal obstruction with nasal discharge?

Documentation of Nasal Obstruction with Nasal Discharge

Document nasal obstruction with nasal discharge by recording at least two symptoms—with nasal blockage/obstruction/congestion OR nasal discharge (anterior/posterior) being mandatory—plus any additional symptoms such as facial pain/pressure or reduced sense of smell, and specify the duration, laterality, and character of the discharge. 1

Core Documentation Requirements

Mandatory Symptom Documentation

You must document at least 2 symptoms, with either nasal obstruction OR nasal discharge being one of them: 1

• Nasal obstruction/blockage/congestion: Document whether the patient reports this as obstruction, congestion, blockage, or stuffiness, or whether you observe it on physical examination 1
• Nasal discharge: Specify whether it is anterior (draining from nostrils), posterior (postnasal drip), or both 1

Additional Symptoms to Document

• Facial pain/pressure/fullness: Note if this involves the anterior face, periorbital region, or manifests as localized or diffuse headache 1
• Reduction or loss of smell: Document hyposmia or anosmia if present 1

Critical Characteristics to Specify

Character of Nasal Discharge

Document whether the discharge is purulent (cloudy or colored) versus clear: 1

• Purulent discharge is cloudy or colored, contrasting with clear secretions typical of viral upper respiratory infections 1
• The discharge may be reported by the patient or observed during physical examination 1
• Note that purulent discharge is one of the three cardinal symptoms with highest specificity for acute bacterial rhinosinusitis when combined with nasal obstruction and/or facial pain 1

Laterality

• Document whether symptoms are unilateral or bilateral 1
• Unilateral symptoms suggest structural problems such as nasal polyps, foreign bodies, septal deformity, or rarely tumors 1

Duration of Symptoms

The duration determines the diagnostic category: 1

• <10 days: Presumed viral rhinosinusitis 1
• ≥10 days without improvement: Suggests acute bacterial rhinosinusitis 1
• <12 weeks with symptom-free intervals: Acute rhinosinusitis 1
• ≥12 weeks: Chronic rhinosinusitis 1

Pattern of Symptom Progression

• Persistent symptoms: Symptoms present continuously for the specified duration 1
• Double-worsening pattern: Initial improvement followed by worsening within 10 days suggests bacterial infection 1
• Severe onset: Unusually severe symptoms in the first 3-4 days may indicate bacterial rhinosinusitis 1

Physical Examination Findings to Document

Nasal Examination

Document the quality and quantity of nasal discharge observed: 1

• Appearance of nasal mucous membranes (pale, edematous, hyperemic, or normal) 1
• Patency of nasal passageways 1
• Presence of mucopurulent discharge, particularly from the middle meatus 1
• Edema or mucosal obstruction, especially in the middle meatus 1
• Presence of nasal polyps 1

Associated Findings

• Dark circles under the eyes (allergic shiners) 1
• Tenderness overlying the sinuses 1
• Signs of complications requiring immediate referral (orbital swelling, proptosis, cranial nerve palsies, facial swelling) 1

Common Documentation Pitfalls to Avoid

Do not diagnose rhinosinusitis based on symptoms alone—objective findings are required for definitive diagnosis: 1, 2

• Symptoms have high sensitivity but low specificity 1
• Anterior rhinoscopy alone is insufficient due to low sensitivity and specificity 2
• Nasal mucus color alone does not differentiate bacterial from viral infection 1
• Fever presence is not useful for distinguishing bacterial from viral disease 1

Sample Documentation Format

"Patient presents with [duration] of bilateral/unilateral nasal obstruction and [purulent/clear] nasal discharge [anterior/posterior/both]. Associated symptoms include [facial pain/pressure, reduced sense of smell, none]. Physical examination reveals [mucosal appearance], [presence/absence of discharge from middle meatus], [turbinate size], [septal deviation if present]. Symptoms [persistent/worsening/double-worsening pattern]." 1