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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!”

HPI

Aidan Evans is a 17-year-old African-American boy presenting to his outpatient internal medicine clinic with complaints of severe congestion, intermittent bilateral rhinorrhea, and persistent sneezing. He states that symptoms are at their worst when he is outdoors, particularly after it rains. Because he spends time outdoors daily, the symptoms have been bothering him consistently over the past 1–2 months, and he is having trouble sleeping due to nasal congestion. He has struggled with these types of symptoms since he was a child, but they have significantly worsened over the past 2 years after his family moved to West Virginia from Arizona. 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

Moderate-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. One younger sibling with no significant medical history.

SH

Is a high school junior; (–) tobacco, (–) illicit drugs, (+) social alcohol use (primarily on weekends when partying with friends); family has two cats and two dogs.

Meds

Diphenhydramine 25 mg PO Q 8 H PRN for allergy symptoms

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

Ciclesonide (Alvesco MDI, 80 mcg/puff) one puff twice daily for asthma

All

Penicillin (hives); cephalexin (trouble breathing)

ROS

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

Physical Examination

Gen

Young African-American boy who appears tired and sounds congested. Although sneezing and rhinorrhea are complaints, they are not ongoing during this evaluation.

VS

BP 112/74 mm Hg, P 68 bpm, RR 18, T 36.9°C; Wt 155 lb (70.5 kg), Ht 5′8″ (173 cm)

Skin

Turgor normal, ...

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