Patient is a very nice 7-year-old male who comes in today to evaluate seasonal allergies and asthma complaints. He has had chronic sinus infection for basically the last couple years. Mother states that they happened all year around. He recently has had four antibiotics in the last seven weeks. He just finished antibiotic last week. She states that he does get better for some time after each antibiotic dose, but then the infection seems to recur and he is required to have antibiotics again. Pediatrics is following his care and has been using cephalosporin antibiotics as well as Augmentin and amoxicillin in the past. Mother is hoping to find out if he has allergies that may be causing chronic sinus congestion leading to these infections.
Patient today complains of nasal symptoms including nose rubbing, clear nasal discharge, postnasal drip, colored nasal drainage, frequent nose blowing and nasal stuffiness, yellow or green discharge in throat. She does state that there does seem to be some seasonal variation to it mostly in spring and fall and has nasal complaints year around. He does have frequent sinus infections. They deny any nasal polyps, TMJ, frequent headaches, aspirin-induced nasal symptoms, nasal surgery or frequent tonsillitis. She does state he has frequent bad colds. She states his nasal symptoms are very severe. They do use Flonase one spray each nostril once daily with moderate relief. He denies any frequent ear infections in the last year. He does admit having eye itching but they deny any redness, tearing dryness, burning, light hurting his eyes, yellow discharge from his eyes and eyelid irritation.
He was diagnosed with reactive airway disease at one and half years old with mild-to-moderate wheezing episodes. He does have ProAir albuterol inhaler. His wheezing seems to be associated with cough and tightness of chest. She was not using his albuterol with cough in the past, but then someone encouraged her to do so and his cough does seem to respond to albuterol. He does have frequent coughing spells, recurrent night cough, coughing up mucus, coughing on exertion, coughing with wheezing, coughing with laughing and lying down. He has not had a chest x-ray done within the last five years.
He did have eczema as a baby, but is currently resolved. He has never been evaluated for allergies before.
1. Recurrent sinusitis.
2. History of frequent ear infections.
3. Status post adenoidectomy.
4. Allergic rhinitis.
5. Allergic conjunctivitis.
6. Mild intermittent asthma.
7. Allergic conjunctivitis.
8. History of chronic sinusitis.
9. Multiple antibiotic allergies including penicillin, cephalexin, erythromycin.
1. At this time, because of patient’s current coughing complaints as well as concern for recurrent sinus infections still that we may want to start with Singulair 5 mg daily two tablets to see if this can help reduce his symptoms. I also encouraged him to continue the use of Flonase one spray each nostril daily. We discussed keeping the dog out of his bedroom and keeping allergy free zone at home to see if this would help reduce his infection status.
2. We did discuss an immunodeficiency workup. Mother would like to try to hold off at this time and see if we can interrupt this round of sinus infections and see how he continues to mature without proceeding with immunodeficiency workup. If he continues to have problems, we will pursue that.
3. I did encourage her to use the ProAir albuterol as needed and particularly during coughing spells and any night coughs to help with his breathing. We will see him in one month’s time.