PRAC 6531 Week 3 Episodic Visit: HEENT Focused Note

PRAC 6531 Week 3 Episodic Visit: HEENT Focused Note

Patient Information:

Initials: G.F.               Age: 23 years old     Sex: Female              Race: Caucasian

S.

CC: “My new location is making my allergies worse.”

HPI: G.F. is a 23-year-old Caucasian female who reports exacerbated allergy symptoms following her relocation from Seattle. She describes symptoms of nasal congestion, sneezing, clear rhinorrhea, and pruritic eyes. Symptoms commenced roughly two weeks ago following her reinitiation of Allegra, which she had previously utilized effectively over the last summer. She asserts that its efficacy has waned. She had previously attempted Claritin and Zyrtec, both of which exhibited comparable diminishing efficacy over time. She indicates that her symptoms exacerbate in the morning and outside, implying exposure to environmental allergens. She refutes the presence of cough, fever, or facial pain. The symptoms are assessed as severe, with a severity level of 7 out of 10. She has asthma but does not utilize daily medication and currently reports no exacerbations or respiratory problems. She has previously utilized over-the-counter nasal sprays but is currently not using any.

Current Medications:

• Allegra (fexofenadine) 180 mg administered once daily, reinstated two weeks prior for allergy management.
• Albuterol inhalers are utilized when necessary for asthma symptoms but are infrequently employed.

Allergies: No known allergies to medications. No documented food sensitivities. Document environmental allergies to pollen and dust.

PMHx: History of non-severe asthma, managed without regular pharmacotherapy. Immunizations are current, including Tdap (last recent dosage in 2023).

PSHx: G.F. is a full-time graduate student and is employed part-time as a barista. She derives pleasure from trekking and reading. She abstains from smoking and consumes alcohol sporadically on weekends. Refutes allegations of drug use. She consistently utilizes a seatbelt and has functional smoke detectors in her residence. She resides with her flatmate in an urban setting. Pets are not permitted. She uses hands-free technology for her cell phone while driving and possesses a robust family and social support network.

Soc Hx: G.F. is a graduate student employed part-time. Resides with a housemate. Prohibition of tobacco consumption. Intermittent social consumption of alcohol. Prohibition of substance consumption. Engages in frequent exercise via hiking. She adheres to safety protocols, including the utilization of seatbelts and the avoidance of mobile phone usage while operating a vehicle. She resides in a region abundant in pollen, which suggests that her surroundings may be exacerbating her problems.

Fam Hx: Mother suffers from seasonal allergies and asthma. Father suffers from hypertension. The maternal grandmother has type 2 diabetes, with no documented history of hereditary cancer. No notable psychiatric or autoimmune disorders are present in the family history.

ROS:

GENERAL: Denies experiencing weight loss, tiredness, or fever.

HEAD: No reports of headaches, trauma, or dizziness.

EENT: Nasal obstruction, sneezing, clear nasal discharge, pruritic eyes. Reports no ear pain, hearing impairment, or pharyngitis.

SKIN: No rashes, lesions, or pruritus reported.

CARDIOVASCULAR: Denies experiencing chest pain, palpitations, or edema.

RESPIRATORY: Denies cough, wheezing, or shortness of breath. Asthma is effectively managed.

GASTROINTESTINAL: Denies nausea, emesis, abdominal discomfort, or alterations in bowel habits.

GENITOURINARY: No dysuria, hematuria, or discharge reported.

NEUROLOGICAL: Denies any weakness, numbness, or convulsions.

MUSCULOSKELETAL: Refutes the presence of joint pain or muscular discomfort.

HEMATOLOGIC: Denies susceptibility to simple bruising or hemorrhage.

LYMPHATICS: No swollen lymph nodes reported.

PSYCHIATRIC: Denies experiencing anxiety, despair, or alterations in mood.

ENDOCRINOLOGICAL: Denies intolerance to heat or cold and excessive thirst.

ALLERGIES: Suspected environmental causes include pollen and dust.

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O.

Vital Signs: Blood Pressure: 124/78 mmHg, Heart Rate: 76 bpm, Respiratory Rate: 16 bpm, Temperature: 98.6°F, Weight: 130 pounds

GENERAL: Patient is alert, cooperative, and exhibits no signs of acute distress.

HEENT: The head is normocephalic and atraumatic. Eye examination reveals clean conjunctivae, devoid of injection or discharge. The tympanic membranes are clean and intact bilaterally. No erythema or effusion present. Nose: Nasal mucosa is edematous and erythematous, accompanied by clear discharge. Swollen turbinates. Throat – Mucosa is moist, with no exudates, erythema, or tonsillar hypertrophy.

NECK: Flexible with complete range of motion, no lymphadenopathy or thyroid hypertrophy.

Diagnostic results: No laboratory tests were conducted during this visit. A clinical diagnosis was established through a comprehensive history and physical examination, indicating allergic rhinitis. Previous skin testing confirmed susceptibility to pollen allergens.

A.

Primary Diagnosis:

1. Allergic Rhinitis (J30.9): G.F. exhibits characteristic symptoms of allergic rhinitis, such as nasal congestion, sneezing, clear rhinorrhea, and pruritic eyes, all of which are exacerbated by seasonal variations and environmental exposure (Siddiqui et al., 2022). Her previous positive skin test for pollen sensitivity, together with enlarged nasal turbinates and clear nasal discharge, reinforces this diagnosis. The persistence and exacerbation of symptoms upon relocation to a new, pollen-abundant environment align with allergen-induced inflammation. The absence of fever, purulent discharge, or systemic sickness rules out more acute conditions, hence affirming allergic rhinitis as the primary diagnosis.

Differential Diagnoses:

2. Non-Allergic Rhinitis (J31.0): Non-allergic rhinitis frequently resembles allergic rhinitis but arises in the absence of a specific IgE-mediated trigger or seasonal pattern (De Corso et al., 2022). G.F. exhibits standard nasal symptoms; however, her history of a positive allergen skin test, seasonal exacerbations, and symptom aggravation upon exposure to outside allergens strongly suggests an allergic origin. Non-allergic rhinitis is generally more prevalent among older individuals and is triggered by irritants such as perfume or smoke rather than pollen. Considering G.F.’s environmental triggers and age, this diagnosis is improbable but remains a secondary consideration if symptoms continue despite allergy-targeted therapies.

1. Sinusitis (J01.90): Sinusitis may lead to nasal congestion and discharge, although it generally manifests with further symptoms such as purulent nasal drainage, facial pain or pressure, headache, and occasionally fever (Allevi et al., 2020). G.F. refutes facial pain and exhibits no indications of systemic sickness. The nasal discharge is clear, and the physical examination shows no pain in the sinuses or abnormal findings in the ears. The lack of indicators for bacterial infection and the presence of seasonal allergy symptoms render sinusitis an improbable primary diagnosis. Nonetheless, it may arise subsequently if nasal irritation and obstruction continue without appropriate intervention.
2. Vasomotor Rhinitis (J31.0): Vasomotor rhinitis is a non-allergic, non-infectious variant of rhinitis provoked by environmental alterations, such as temperature, humidity, potent odors, or irritants (Arslan et al., 2020). Symptoms consist of nasal congestion and rhinorrhea, generally absent of pruritus or sneezing. In contrast to allergic rhinitis, it does not involve an IgE-mediated mechanism and typically yields negative results on skin tests. Despite G.F.’s claims of allergy-related triggers and a history of positive allergen tests, vasomotor rhinitis must be considered due to the ongoing symptoms despite antihistamine treatment. Nonetheless, her seasonal pattern and external stimuli render this diagnosis improbable.

• Clinical assessment, allergy history, previous dermatological testing, and no additional laboratory tests.
• F. was instructed to cease the use of Allegra due to inadequate symptom management.
• She was advised to resume Zyrtec (cetirizine) 10 mg daily, considering her previous partial response and the reduced out-of-pocket expense resulting from the absence of prescription coverage (Zhang et al., 2021).
• She was prescribed Nasonex (mometasone furoate) nasal spray, to be administered as two sprays per nostril daily for three weeks. This corticosteroid spray effectively diminishes nasal irritation and possesses a favorable side effect profile (Siddiqui et al., 2022).
• Nonpharmacological measures, such as refraining from outdoor activities during peak pollen periods, using a HEPA filter, and employing saline nose rinses, were recommended (Zhang et al., 2021).
• The patient received instruction on the correct technique for nasal spray administration to enhance effectiveness and reduce systemic absorption.
• A follow-up appointment in four weeks has been arranged to evaluate the reaction and ascertain the necessity of a referral to an allergist for immunotherapy.

Reflection: In future similar situations, I would prioritize the prompt administration of a nasal corticosteroid over relying solely on oral antihistamines, as data indicate their superior efficacy in managing nasal symptoms associated with allergic rhinitis. Investigating insurance constraints at the outset of the visit is essential for customizing treatment regimens that are both efficacious and economically viable (Siddiqui et al., 2022). Given G.F.’s age and busy lifestyle, patient education prioritized trigger avoidance, compliance with nasal spray, and regular antihistamine usage. Considering her established history of asthma, the plan included monitoring for respiratory symptoms and providing education on the early indicators of exacerbating asthma. Health promotion initiatives encompassed advice on allergy avoidance, preservation of indoor air quality, and assessment of inhaler usage technique (Zhang et al., 2021). The discussion focused on the sustained prioritization of immunization, a secure living environment, and consistent follow-up to guarantee long-term management and avert problems.

References

Allevi, F., Fadda, G. L., Rosso, C., Martino, F., Pipolo, C., Cavallo, G., Felisati, G., & Saibene, A. M. (2020). Diagnostic Criteria for Odontogenic Sinusitis: A Systematic Review. American Journal of Rhinology and Allergy, 35(5), 713–721. https://doi.org/10.1177/1945892420976766

Arslan, İ., Muluk, N. B., & Milkov, M. (2020). What is vasomotor rhinitis? In Springer eBooks (pp. 25–37). https://doi.org/10.1007/978-3-030-50899-9_4

De Corso, E., Seccia, V., Ottaviano, G., Cantone, E., Lucidi, D., Settimi, S., Di Cesare, T., & Galli, J. (2022). Clinical Evidence of Type 2 Inflammation in Non-allergic Rhinitis with Eosinophilia Syndrome: A Systematic Review. Current Allergy and Asthma Reports, 22(4), 29–42. https://doi.org/10.1007/s11882-022-01027-0

Siddiqui, Z., Walker, A., Pirwani, M., Tahiri, M., & Syed, I. (2022). Allergic rhinitis: diagnosis and management. British Journal of Hospital Medicine, 83(2), 1–9. https://doi.org/10.12968/hmed.2021.0570

Zhang, Y., Lan, F., & Zhang, L. (2021). Advances and highlights in allergic rhinitis. Allergy, 76(11), 3383–3389. https://doi.org/10.1111/all.15044

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