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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Recognize common signs and symptoms associated with allergic rhinitis.

  • Educate patients on appropriate measures to limit or avoid exposure to specific antigens.

  • Select an appropriate pharmacotherapeutic regimen for managing allergic rhinitis, focusing on specific symptoms.

  • Educate patients with allergic rhinitis on appropriate medication use, including instillation technique for intranasal medications.

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PATIENT PRESENTATION

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Chief Complaint

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“I can’t breathe! I feel congested around the clock and am constantly sneezing.”

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HPI

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James Joseph Patrick is a 19-year-old African-American man presenting to his family medicine clinic with complaints of severe congestion and persistent sneezing. He states that symptoms are at their worst immediately upon returning to his apartment every evening and that they started last August when he moved to his new apartment. Prior to this move, he noticed symptoms similar to these on a much more sporadic basis; since the move they have been bothering him every day, and he is having trouble sleeping. He hasn’t noticed a fever or a sore throat, but the symptoms are becoming unbearable. He is seeking advice on how to cope with and manage these symptoms.

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PMH

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Mild-persistent asthma (diagnosed when he was age 13)

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FH

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Father, age 44, with a history of asthma and allergic rhinitis. Mother, age 38, with a history of migraines. No siblings.

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SH

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Lives in an apartment close to his university and place of work; (–) tobacco, (–) illicit drugs, (+) alcohol use (primarily on weekends when partying with friends); has two cats that he adopted when he moved into his new apartment.

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Meds

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  • Diphenhydramine 25 mg PO Q HS (helps him sleep at night)

  • Albuterol MDI two puffs Q 6 H PRN (uses roughly one inhaler per year for asthma symptoms)

  • Fluticasone (Flovent HFA, 44 mcg/puff) two puffs twice daily for asthma

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All

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Penicillin (hives)

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ROS

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Denies headaches; no shortness of breath, wheezing, chest pain, or abdominal discomfort

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Physical Examination

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Gen
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Young African-American male who appears tired and sounds congested. Although sneezing is a main complaint, he has not sneezed at all during this visit.

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VS
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BP 112/74 mm Hg, P 68 bpm, RR 18, T 36.9°C; Wt 175 lb, Ht 5′10″

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Skin
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Pale, turgor normal, no rashes or lesions

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HEENT
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NC/AT; PERRLA; EOMI; (–) periorbital edema or discoloration; TMs are intact; (+) swollen nasal mucous membranes and nasal turbinates with a pale, bluish hue and discharge down ...

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