Exploring Allergic Reactions: A Case Study

Patient: M.C
Date of Birth: 3/06/1996
Date of Exam: June 9, 2015

Chief complaint: “I am stuffed up and my eyes are watering and itchy.”

Subjective

History of Present Illness:

M.C is a 19 year old male that presents to the office complaining of sneezing, nasal congestion, watery, itchy eyes, and rhinorrhea that have progressed over the last eleven days. His symptoms tend to be worse in the mornings when he wakes up and he has had a sore throat upon awakening that improves as the day progresses. He has also been getting mild sinus pressure 2/10 pain located around the eyes, that are relieved with OTC Tylenol. He has recently moved to Tampa from New York and has not had symptoms similar to this before. He does mention, however, that in the past smoke has caused him to get itchy

eyes.

Review of Systems:

General: Denies any fever, chills, night sweats, or weight loss.
Neurologic: Denies any weakness, or dizziness.
HEENT: Denies headaches, sinus pressure as described in HPI, denies hearing changes or ringing in his ears, or any discharge. He states he has nasal congestion, post nasal drip, and watery, itchy eyes. He does not wear contact lenses. He denies any lymph node tenderness. He states his sense of smell is slightly decreased. Sore throat as described in HPI.
Respiratory: He denies any chest congestion, though he does have a cough and produces a mild amount of clear secretions, which he thinks are from the post nasal drip. He has no hemoptysis or pain with respirations. He denies any shortness of breath, dyspnea, or wheezing.
Cardiovascular: Denies any chest pain or palpitations, or racing beats.
Gastrointestinal: Denies any change in appetite, heartburn, nausea, vomiting, diarrhea, or change in bowel habits.
Musculoskeletal: denies any joint or rib pain or muscle aches.
Psychiatric: Denies any feelings of anxiety or depression or difficulty concentrating.

Medications: Tylenol 500 mg PO as needed for headaches. Mucinex 1200 mg BID for congestion. No other current daily medications

Allergies: No know medication allergies. No Food Allergies. No Latex Allergies. No Environmental Allergies that he is aware of at this time.

Past Medical History: Childhood vaccinations are up to date. Additionally he has completed his Hepatitis B and Hepatitis A vaccine series and had the Meningococcal vaccine. He has had no surgeries.

Family History: Father 50, alive and in good health. Mother 48, alive and in good health. Patient unaware of any family medical history, and does not know of his patients having any allergies. He has no siblings.

Social History: Patient lives with a friend in an apartment and is in his second year at community college. He likes to run in through a local park trail. He denies tobacco use but states he will sometimes have 3-4 beers a week with friends at home. He denies any recreational drug use. He will drink a rockstar 1-2 times per week to help study. He is sexually active and states that he uses condoms every time. He states that he is happy and denies any psychiatric problems at this time. He does not work.

Objective

Temp - 98.4 Pulse - 76 Respirations - 16 BP - 112 / 78 Oxygen Saturation 100% On RA. Height - 72 inches Weight - 180 lbsBMI - 24.4

Patient M.C is a white male who appears well nourished, with good hygiene, and in no acute distress.

HEENT: Head appears normocephalic and symmetric. There is mild sinus tenderness (2/10) upon palpating the maxillary sinuses. Conjunctival injection present bilaterally, no orbital edema present. Extra ocular movements intact. PERRLA. No jaundice present. There is a mild amount of water-like discharge present bilaterally in the eyes. No AV nicking or hemorrhage identified. Ears are symmetric. Mild cerumen present, no erythema or discharge present. Tympanic membranes are intact and pearly gray color. A sharp cone of light is present bilaterally. The oral mucosa appears pink with a normal tongue. The posterior oropharynx has mild erythema. No edema of the tonsils noted. Voice is not hoarse. The nasal passages bilaterally have rhinorrhea and appear boggy, with edema of the turbinates, and mild erythema of nasal mucosa. No blood noted. The neck is soft and non tender, no thyroid enlargement noted and trachea is midline. No lymphadenopathy noted in the submental, cervical, or supraclavicular lymph nodes.

Respiratory: Symmetric chest expansion noted. Respirations unlabored and with ease. Chest shape normal with no lesions noted. Breath sounds clear to auscultation anteriorly and posteriorly and resonant to percussion.

Cardiovascular: Heart sounds S1 and S2 noted on auscultation. Heart rate and rhythm normal. Absence of murmur, clicks, S3 or S4. The point of maximal impulse was felt at the 5th intercostal space midclavicular line. JVD was absent. No thrills or heaves palpated. No bruits over the carotids were detected. No edema noted. Capillary refill <2 seconds.

Gastrointestinal: Bowel sounds active in all four quadrants, with tympani noted to percussion. Abdomen is soft, no distention noted. No bruit identified. No pulsations noted. No organomegaly.

Musculoskeletal: RoM and strength equal in upper and lower extremities. No pain noted over ribs upon palpation.

Assessment

Allergic Rhinitis - Patient recently moved to florida and had not experienced these symptoms when living up north. On exam the patient has conjunctival injection and watery drainage from the eyes. The turbinates are boggy and rhinorrhea is present. He is sneezing and nasal congestion. (Most Likely Diagnosis)
Sinusitis - Only minimal pain noted over sinuses with palpation (2/10). No color to nasal or oral mucous and no blood noted in mucous. Patient does not exhibit any fevers and has very limited head aches. There is some erythema noted in the throat and nasal passages.
Viral Rhinitis - Similar symptoms as described with allergic rhinitis, however, the symptoms are not acute in onset as with a virus, but instead have progressed for nearly two weeks.

Conjunctivitis - Patient has conjunctival injection with clear watery discharge. The patient does not, however, present with typical eye crusting.

Plan

Flonase 50 mcg spray OTC - instruct patient to use to use one spray per nostril daily and increase to two sprays per nostril daily if no improvement. Instructed patient on proper use of the nasal spray and to avoid spraying medication directly into nostril.

Allegra 180 mg OTA - this medication should not make the patient drowsy and since he is a student it is helpful so that he does not get tired during class and can study.

If the patient feels like the Mucinex is helping he can continue to take it, if not, he may discontinue it. The patient was also instructed to try and avoid triggers of his allergies. If running through the park worse his symptoms he might try running on Bayshore instead. If smoke produced symptoms, as he stated they have in the past, he should avoid it. It might be helpful for the patient to keep a journal of triggers as

well.

The patient should follow up in 2-3 weeks or as needed if his symptoms get worse or he starts to develop any fever, colored sputum / nasal discharge / bloody nasal discharge, increased cough, shortness of breath, increased redness in eye color, or crust in his eyes.

Additionally, if the patient symptoms do not resolve, he may benefit from a referral to an allergist for allergy testing and an alteration of his antihistamine or the addition or a leukotriene receptor antagonist like Singulair.