The patient is an 11-year-old female who is brought in by her mother to discuss her severe allergies. She states that ever since she was 4 years old she has developed migraines and this constant nasal congestion that makes her hard for her to sleep because she cannot breathe through her nose. She is wondering if the migraines may be associated with seasonal allergies as well. She currently complains of nasal symptoms including sneezing, nose rubbing, clear nasal discharge, postnasal drip, frequent nose blowing, nasal stuffiness, mouth breathing, frequent throat clearing, sore throat, decreased smell, itching inside ears, frequent nose bleeds, and decreased hearing. This occurs every day. It can be a little better in the winter, but is always present in spring, summer, and fall. She does have occasional sinus infections about two to three per year due to this constant congestion and frequent bad cold. She denies nasal polyps, TMJ, aspirin-induced nasal symptoms, nasal surgery, and frequent tonsillitis. Her nasals symptoms are very severe. They have tried Benadryl, Claritin, Zyrtec, Sudafed, Afrin, and Flonase with very little relief. They have used Afrin more lately and it does help, but they only use it intermittently.
She does have occasional ear infections two since December, lightheadedness, and mild hearing impairment. She denies dizziness.
She does have eye itching, dryness, burning, light hurting her eyes. She denies redness, tearing, yellow discharge from eyes, eyelid swelling, or eyelid irritation that occurs a lot of the time.
She denies a history of wheezing or lung troubles, frequent coughing spells or recurrent night cough.
She does not have any history of eczema, hives, or allergic skin problems. She was evaluated by Dr. via a blood test and was positive to trees, grasses, and weeds.
1. Acute allergic rhinitis.
2. Allergic conjunctivitis.
3. Frequent sinus and ear infections.
1. At this time, I do think patient would benefit from long-term management of allergy immunotherapy to reduce medication needs and prevent the atopic march. She would also hopefully have resolution in some of her migraine triggers and frequent infections.
2. I do want her to try using fluticasone nasal spray consistently once spray each nostril daily to see if this will help control symptoms at this time plus Zyrtec 10 mg daily on a regular basis to help with her allergy season until the immunotherapy becomes effective. We will follow for first shot appointment.