Patient presents with symptoms consistent with sinus disease, including sinus pressure, facial pain, nasal congestion, and thick nasal discharge.  Onset of symptoms reported as [duration].  Associated symptoms may include headache, cough, fatigue, and decreased sense of smell or taste.  Patient reports [triggers, if any, e.g., seasonal allergies, exposure to irritants].  Physical examination reveals [objective findings, e.g., tenderness to palpation over sinuses, erythematous nasal mucosa, purulent drainage].  Differential diagnoses considered include viral upper respiratory infection, allergic rhinitis, and bacterial sinusitis.  Based on clinical presentation and examination findings, the diagnosis of sinusitis is made.  Severity is assessed as [acute, subacute, chronic].  Treatment plan includes [e.g., saline nasal irrigation, intranasal corticosteroids, oral decongestants, antibiotics if bacterial infection suspected, antihistamines if allergies contributing].  Patient education provided regarding symptom management, potential complications, and follow-up care.  Follow-up scheduled in [duration] to assess response to treatment.  ICD-10 code [appropriate code based on type and acuity of sinusitis] assigned.  CPT codes for evaluation and management services documented.