Patient is 10-year-old girl who is here with her mother and brother. She has significant problems with nasal symptoms including sneezing, itching of the nose, nose rubbing, clear nasal discharge, postnasal drip, colored nasal drainage occasionally, frequent nose blowing, nasal stuffiness, mouth breathing, frequent throat clearing, sore throat, itching inside the ears, and frequent nosebleeds. These symptoms seem to occur everyday all time of the year. She has had frequent sinus infections as well and approximately six months ago being the last one that required antibiotics. She denies any problems with nasal polyps, TMJ, frequent headaches, frequent bad colds, tonsillitis, or ear infection. Her mother states that her nasal symptoms are severe. They have tried using Claritin in the past as well as saline nasal spray to help with not much relief.
She also complains of some eye symptoms including itching, redness, and tearing but denies any drainage, burning, yellow discharge, eyelid swelling or eyelid irritation.
She denies any history of lung problems or wheezing after exercise or after infections.
She does have some eczema problems mostly on her elbows that they use Cetaphil cream or Lubriderm cream for. She seems to not like utilizing these lotions on a daily basis. Mother struggles getting her to use it, but when she does it works well. She has never been tested for allergies in the past.
1. Allergic rhinitis.
2. Allergic conjunctivitis.
3. Concern for food allergy.
4. History of frequent sinus infection.
1. We will start fluticasone one spray each nostril twice daily and I encouraged her to use this throughout the fall season because she has such a significant allergies to wheat.
2. She can continue to use the saline nasal sprays intermittently to help clear out some congestion as well as Claritin although I recommended Zyrtec being a more effective medication using that 10 mg Zyrtec daily to help reduce allergy symptoms.
3. I told her that she can try eliminating certain foods to see if there is any relation with diarrhea or nasal congestion although I encouraged her to use a healthy nutritious diet and discussed the fact that most allergies to foods do not present in this way including increased nasal stuffiness and diarrheal problems.
4. We discussed the possibility of inducing allergy immunotherapy in the future for long-term treatment since she is so significantly positive as well as reduction in medication cost and use on a daily basis.
5. We will follow up in two weeks’ time with patient to see how the Flonase and Zyrtec medication regime is working for her at this time.