Allergic rhinitis

Patient is 6-year-old boy who is brought in by his mother to evaluate a chronic cough that he has had since approximately he was three years old. She states that this cough is all the time and in the night at worse and also is worse in cold weather and during exercise. She states that mostly it is dry cough but sometimes he coughs up some phlegm as well. He does not know where this cough may be coming from if it is due from postnasal drip or if it is coming from the lungs. He does not seem to have a lot of nasal congestion other than occasional. He only has colored nasal drainage but does complain of frequent throat clearing. She has noticed some seasonal allergies in fall and spring being the worst time where he has increase in the nasal congestion. He also has some frequent headaches at the temples. She denies any problems with sinus infection, nasal polyps, frequent bad cold, or frequent tonsillitis. She states that his nasal symptoms are mild-to-moderate and she uses Zyrtec occasionally and that seems to help with his nasal congestion. She denies him ever having trouble with eyes that are itching, red, tearing, dryness, or burning. He mostly does get the headaches and sore throat due to coughing. These are the only other complaints other than the cough that he has. She does feel that she can hear some mild-to-moderate wheezing episodes when he is coughing more and during this times of exertion at night or in cold air. She has never used any albuterol inhalers or any other treatment for this. He has never had any problems with his lungs when he was young causing hospitalization. He has never used any nebulization or any corticosteroids to help resolve some breathing problems.

He was breastfed for approximately three weeks but had problems watching so he was on formula. He was a normal vaginal delivery and was full term. She does admit to him having frequent coughing spells, recurrent night cough, coughing of mucus, shortness of breath with exercise, coughing on exertion, coughing on wheezing, coughing with laughing, and coughing with lying down. He has not had a chest x-ray done within the last five years.

ASSESSMENT:
1. Cough possible reactive airway disease.
2. Allergic rhinitis.
3. Exercise-induced bronchoconstriction.

PLAN:
1. At this time due to his cough being frequent at night during exercise and cold air it may be exhibiting some reactive airway disease and we can try albuterol inhaler one puff every four to six hours or as needed at times of trouble. I encouraged her for the next two weeks to try using an albuterol inhaler each night before bed to see if the coughing at night resolves.
2. She can also continue use Zyrtec one teaspoon as needed for allergy symptoms and if he has increase in nasal congestion or throat clearing. We will see how this treatment works. If he does not seem to resolve with albuterol use, we may consider more of etiology of nasal congestion or reflux.
3. We will follow up in two weeks’ time to see how he is doing with the albuterol plus spacer.

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