Chronic Rhinitis follow-up

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Returns for an ‍allergic rhinitis follow-up

Last visit was ‍ ‍months ago

Progress since last visit: ‍unchangedimprovedworsenedvariable in intensityresolved



Updates on symptoms:

‍sneezing

‍runny nose, ‍clearcolored

‍stuffy nose

‍itchy eyes

‍watery eyes

‍cough, ‍non-productiveproductive of ‍clearcolored phlegm

‍fatigue

‍headache, ‍diffuse, ‍persistentintermittent, ‍pressurethrobbing, ‍mild

‍earache

‍postnasal drip

‍reduced sense of taste or smell



Allergies reviewed: ‍none, ‍pollen, ‍dust mites, ‍cat dander, ‍dog dander, ‍animal dander, ‍mold

Allergen avoidance: ‍nonestaying indoors during high pollen count, ‍effectiveineffective



Medication tried: ‍antihistamines, ‍decongestants, ‍nasal sprays, ‍eye drops, ‍effectiveineffective, ‍adverse effect, ‍good adherence

Immunotherapy: ‍noneongoingcompleted, ‍effectiveineffective

Diagnostic tests performed: ‍noneskin prick testblood testCT scan





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Eyes: conjunctiva/sclera ‍normal, lids/lashes ‍normal

Ears: tympanic membranes ‍normal ‍, auditory canal ‍ on ‍rightleft, hearing ‍intact

Nose: ‍clear, discharge ‍clear, ‍

Throat: ‍normal, ‍erythema, ‍exudate, ‍

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Skin: ‍rashlesions on ‍





ASSESSMENT:

‍Allergic rhinitis ‍likelysuspectedpossible, ‍well-controlled

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:

- ‍Intranasal saline

- ‍Intranasal corticosteroids

- ‍Oral antihistamines

- ‍Intranasal antihistamines

- ‍Oral decongestants

- ‍Intranasal decongestants

- ‍Montelukast

- Avoidance of allergens

- Immunotherapy if symptoms are severe and not controlled by medications

Further care:

- Referral to allergist

- Referral to otolaryngologist

- Follow-up in ‍ ‍monthsyears

- Return if symptoms worsen or if new symptoms develop such as nasal polyps, chronic sinusitis, or if symptoms are not controlled by medications