Wiki Problem complexity for acute, recurrent sinusitis

[Bernadette10]

Would the problem complexity for acute, recurrent sinusitis be low or moderate? I'm thinking low since recurrent doesn't always mean chronic, does it? A prescription was given, so moderate risk, but no diagnostic tests were done, so the level depends on the problem complexity. I'm thinking low since ear fullness and sore throat aren't systemic symptoms, are they?
Acute, uncomplicated vs. acute with systemic symptoms (codingintel.com)

New patient - Pt here to establish care and also c/o sinus congestion, ear fullness, and sore throat for 2 weeks.

Review of Systems
Constitutional: Negative.
HENT: Positive for ear pain, postnasal drip, sinus pressure and sore throat.
Eyes: Negative.
Respiratory: Negative. Negative for chest tightness and shortness of breath.
Cardiovascular: Negative for chest pain.

Exam
Vitals and nursing note reviewed.
Constitutional:
Appearance: Normal appearance.
HENT:
Head: Normocephalic.
Right Ear: Tympanic membrane is bulging.
Left Ear: Tympanic membrane is bulging.
Nose:
Right Sinus: Frontal sinus tenderness present.
Left Sinus: Frontal sinus tenderness present.
Mouth/Throat:
Mouth: Mucous membranes are moist.
Pharynx: Oropharynx is clear. Posterior oropharyngeal erythema present.
Cardiovascular:
Rate and Rhythm: Normal rate and regular rhythm.
Pulses: Normal pulses.
Heart sounds: Normal heart sounds.

Acute recurrent frontal sinusitis
- predniSONE (DELTASONE) 20 mg tablet; Multiple Dosages:Starting Fri 3/24/2023, Until Sat 3/25/2023 at 2359, THEN Starting Sun 3/26/2023, Until Mon 3/27/2023 at 2359, THEN Starting Tue 3/28/2023, Until Wed 3/29/2023 at 2359Take 2 tablets by mouth daily for 2 days, THEN 1 tablet daily for 2 days, THEN 0.5 tablets daily for 2 days., Normal
- azithromycin (ZITHROMAX) 250 mg tablet; Take 2 tablets (500mg) once today (on Day1), followed by 1 tablet (250mg) once daily on Day 2 through 5., Normal

Acute recurrent frontal sinusitis
- predniSONE (DELTASONE) 20 mg tablet; Multiple Dosages:Starting Fri 3/24/2023, Until Sat 3/25/2023 at 2359, THEN Starting Sun 3/26/2023, Until Mon 3/27/2023 at 2359, THEN Starting Tue 3/28/2023, Until Wed 3/29/2023 at 2359Take 2 tablets by mouth daily for 2 days, THEN 1 tablet daily for 2 days, THEN 0.5 tablets daily for 2 days., Normal
- azithromycin (ZITHROMAX) 250 mg tablet; Take 2 tablets (500mg) once today (on Day1), followed by 1 tablet (250mg) once daily on Day 2 through 5.

 

[csperoni]

This looks to me like a low level problem of acute uncomplicated. Ear fullness and sore throat would be expected signs/symptoms of sinusitis (even without a medical degree).
Other than the provider having the word "recurrent" there, I don't see anything addressing that which could possibly bring it up to moderate. It says symptoms for 2 weeks. If it said sinusitis treated w ABX 4 times in past 3 months, or finished previous prescription 1 week ago, but problem persists - SOMETHING to show complexity, I would consider moderate. As is, I call it low level problem.