Allergic Rhinitis follow-up
Age: years old
Gender:
HISTORY:
Returns for an follow-up
Last visit was ago
Progress since last visit:
Updates on symptoms:
,
, of phlegm
, , , ,
Allergies reviewed: , , , , , ,
Allergen avoidance: ,
Medication tried: , , , , , ,
Immunotherapy: ,
Diagnostic tests performed:
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Eyes: conjunctiva/sclera , lids/lashes
Ears: tympanic membranes , auditory canal on , hearing
Nose: , discharge ,
Throat: , , ,
Neck: , , , c-spine
Heart: , ,
Lungs: , ,
Skin: on
ASSESSMENT:
,
DDx: allergic rhinitis, non-allergic rhinitis, chronic sinusitis, upper respiratory infection, nasal polyps, idiopathic rhinitis, drug-induced rhinitis, pregnancy rhinitis, atrophic rhinitis, GERD, environmental irritants, nasal septal deviation, adenoid hypertrophy
PLAN:
Investigations:
- Allergy testing
- CT scan of the sinuses
Treatments:
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-
-
-
-
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- Avoidance of allergens
- Immunotherapy if symptoms are severe and not controlled by medications
Further care:
- Referral to allergist
- Referral to otolaryngologist
- Follow-up in
- Return if symptoms worsen or if new symptoms develop such as nasal polyps, chronic sinusitis, or if symptoms are not controlled by medications
HISTORY: EXAM: ASSESSMENT: PLAN: