Hypertrophy of tonsils

Patient is 6-year-old boy brought in by his mother to evaluate for allergies. She states that he has had this chronic nasal congestion that is beginning to get worse and worse. She first noticed it when he was about 3 years old. When he was about 2.5 years old. She was unsure if he was having allergy troubles due to Boise or if it was because he started preschool and started beginning having some infection, but over the last six months, his nasal symptoms have been constant. He does have a history of wheezing as well as the baby usually in cold weather and temperature changes and with allergy triggers. This has been getting better since he has been getting older. He currently complains of nasal symptoms including sneezing, nose rubbing, clear nasal discharge, colored nasal drainage, frequent nose blowing, nasal stuffiness, mouth breathing, and frequent throat clearing, hoarseness. This occurs every day and seems to be constant year around. He denies sinus infection, nasal polyps, TMJ, frequent headaches, aspirin-induced nasal symptoms, nasal surgery, or frequent tonsillitis. He does get frequent bad colds or possible allergy, mom is not sure. He did have pneumonia in January, but resolved from this as well. She states that his nasal drainage is mostly clear but can be green at times. It is moderate in severity. She has used Flonase, Nasacort, Zyrtec, Claritin, and it does not help at all.

He denies frequent ear infections, dizziness, lightheadedness, or hearing impairment.

He does have eye tearing, but denies itching, redness, dryness, burning, light hurting his eyes, yellow discharge from eyes, eyelid swelling or eyelid irritation. This occurs some of the time.

He does have mild-to-moderate wheezing episodes. It does not seem to affect his exercise associated with cough. He does have an albuterol nebulizer to use as needed. He uses it currently about three to four times per year. He does have occasional frequent coughing spells and recurrent night cough. Mom thinks it may be due more to postnasal drip. This has been getting better since he has gotten older. He denies any history of allergic skin problems, including eczema or hives. He has never been evaluated for allergies before.

ASSESSMENT:
1. Chronic nasal congestion.
2. Hypertrophy of tonsils.
3. Possible hypertrophy of adenoids.
4. Pediatric wheezing resolving with age.

PLAN:
1. At this time, I do believe that is having some significant allergy troubles. When looking on physical exam, he does not appear very allergic and is not having a seasonal variation in his symptoms. I do see that his tonsils are moderately sized, although his airway is patent, I do worry that he may have enlarged adenoids that need to be evaluated by Ear, Nose, & Throat.
2. I do slightly am concerned that this could be a chronic sinusitis infection, although as a 6-year-old I am hoping that is not the case. It is mostly clear nasal drainage and may be more due to enlarged adenoids. I would like him to get referred over to Ear, Nose & Throat to see if they can get this evaluated.
3. We will continue to monitor his pediatric wheezing. Mom states that it has been getting better and better as older he gets and now only uses the albuterol maybe three times a year. We will continue to monitor this and if she has any troubles with this, she will come to see me.

Advertisements

Leave a Reply