Patient is 46-year-old female who states for the last two years she has had very severe nasal congestion to the point where she just cannot breathe through her nose at all. It makes her have trouble lying down to sleep. She needs to prep herself up with three pillows to breathe through the night. She does have some sinus pressure and pain associated with this. She does feel that this has been continuous ever since last winter. She has had a trouble in the past with the bad stuffy nose, but nothing this severe and nothing this persistent.
She currently complains of nasal symptoms including sneezing, itching of the nose, nose rubbing, clear nasal discharge, postnasal drip, nasal stuffiness, mouth breathing, snoring, and heartburn. This occurs almost every day and seems to be around this year. She denies any history of sinus infections, nasal polyps, or TMJ. She does get frequent headaches in the frontal area. She denies aspirin-induced nasal symptoms, nasal surgery, frequent bad cold, or frequent tonsillitis. This can be severe. She currently uses montelukast which helps with her runny nose, fluticasone nasal spray, and azelastine nasal spray twice a day and she feels that this helps moderately.
She denies frequent ear infection or hearing impairment. She does have occasional dizziness and lightheadedness.
She does have some eye itching and tearing, denies redness, dryness, burning, light hurting her eyes, yellow discharge from eyes, eyelid swelling, or eyelid irritation. This occurs a lot of the time.
She denies any history of wheezing or asthma, any frequent coughing spells, or recurrent night cough. She did have a chest x-ray done in February 2015 in Taipei, Taiwan. She does have a rash that produces on her neck occasionally and she has been given hydrocortisone ointment for this and it does help. She also has scalp itching that really bothers her. She does not know if any flaking of the skin or any lesions or bumps, but her scalp is very itchy. She has never been evaluated for allergies before.
1. Chronic nasal congestion.
2. Acute allergic rhinitis.
3. Allergic conjunctivitis.
4. Dermatitis, unspecified, currently controlled.
5. Scalp itching.
1. At this time, she does appear to be severely congested and does not have any patency through her nose. I do not think the medication is actually getting to where it needs to go. I do want her to try using QNASL 80 mcg one spray each nostril twice daily to see if this gets into her sinuses a little bit better. We did discuss that this could be a possible chronic rhinosinusitis and she may need a treatment with an antibiotic. She also may benefit from a short burst of prednisone to clear up some of the severe inflammation.
2. She would like to try the nasal spray first and see if that helps a little bit and if she continues to have problems, then she will come back and see me in two weeks and we will try treatment with antibiotic and prednisone as I am concerned that this will not clear up until we do so. She will also continue taking her montelukast.
3. We will follow up in two weeks to see how she is doing.