Patient is a product of full-term, in fact one month past to delivery. He was 10 pounds when born. His mother was diagnosed with a placental infection and he was placed in a NICU for one week’s time due to problems breathing and reflux and having not been able to put food down. He had a lung infection and lost 3 pounds at that time. After that week, he was brought home, fully recovered. He was not breast-fed. They had complications with breast-feeding and could not tolerate soy or cow’s milk, so he was fed with goat milk until he was one year’s of age. Then he was introduced to milk products and did tolerate them okay.
The mother complains that he has a stuffy itchy nose all the time, frequent nose swelling, mouth breathing, throat clearing, sore throat, hoarseness, itching inside of the ears, snoring a lot, and belching a lot. He has these symptoms year around and the fires and the air qualities make them worse. He also has certain foods trigger his nasal symptoms including tomatoes especially and vegetables, cheese, and milk products. He has had several sinus infections in the past and also several strep throat infections and has chronic ear infections. The mother states that he has been on continued dose of antibiotics most of his life due to these problems. He did have tubes placed in his ears but they were taken out approximately a year ago for complications and he is noted to have ear complication since then. He actually goes to see an ear, nose, and throat doctor for his chronic ear infections. He also has tonsils and adenoids removed approximately one year ago as well.
The mother does state that he has some mild-to-moderate wheezing episodes, which does limit his exercise as well. She states that wheezing seems to happen March through November mostly in the morning, evening, and afternoon. It is usually associated with a cough. She is constantly going to the doctor and he still has coughing episodes at 12 plus times per year. He uses albuterol p.r.n. He has only used this medication once and probably he only needed it once. The wheezing is pretty mild compared to the coughing.
He does have frequent night coughing spells that are the worst complaint and he does not use albuterol for this. He also has shortness of breath with exercise, coughing with laughing, and coughing with lying down. He has in the past been told by the practitioner that he might have asthma. He is not having a cough at this time. He has not had any problems with eczema or atopic dermatitis in the past or currently. He has been infected of allergies in the past with an ear, nose, and throat doctor. They did a blood test done showing positive to most of foods and seasonal allergies and was not determined to be clinically significant or not.
Patches have contributed to his allergic problems to include respiratory infections going to his lungs, change in weather, and wind forms caused nasal symptoms, inherent allergies, allergens, postnasal, and lung symptoms in the form of animals specifically the cats and parrots caused very bad nasal symptoms. So, they have to get rid of their animals.
1. Rhinitis, unspecified.
2. Cough with possible asthma.
3. Concerns for food allergies.
4. Concerns for immunodeficiency.
5. Chronic ear infections.
1. We will start Flonase nasal spray one spray once daily to help with his nasal symptoms.
2. Start Singulair 4 mg two tablets daily and that helps to reduce much of his inflammation.
3. Prednisone 50 mg/5mL syrup two teaspoons daily as well to further identify if he has some inflammation.
4. Blood workup of immunodeficiency including lymphocyte subset panel 1, anti-pneumococcal titer, anti-diphtheria titer, and anti-tetanus titer, mannose binding lectins and CBC with differential, immunoglobulins quantitative and qualitative. He is also tested for some foods that are troublesome and RAST testing including tomatoes, rice, milk, wheat, and soy.
5. We will follow up in two weeks’ time to see how the treatments are going and he will go with the results of the lab testing.