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LEARNING OBJECTIVES

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

  • 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.

PATIENT PRESENTATION

Chief Complaint

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

HPI

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.

PMH

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

FH

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

SH

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.

Meds

  • 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

All

Penicillin (hives)

ROS

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

Physical Examination

Gen

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.

VS

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

Skin

Pale, turgor normal, no rashes or lesions

HEENT

NC/AT; PERRLA; EOMI; (–) periorbital ...

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