A 42-year-old Caucasian female presents to the clinic with complaints of runny nose, itchy eyes, right ear fullness, cough, and fatigue ongoing for five days. She states that symptoms seem to be worse when she is outside working in the yard, and she also states that she “feels a little bit better when resting.” The patient states that her cough is non-productive, and her nasal discharge is clear in color. She has tried taking Benadryl at night before bed, which she reports did provide some relief. She also reports a history of childhood allergies but states she has not had any problems recently “that she knows of until now possibly.” She denies any other complaints currently.
Allergic rhinitis is an immunoglobulin E (IgE) mediated inflammatory disease which involves the mucous membranes of the nose, middle ear, eyes, pharynx, and sinuses. When specific substances are inhaled into the nasal cavity, such as pollen, it binds to the IgE mast cells. Histamine, a type of mediator that is produced, is released when immunoglobulin E antibodies bind to the mast cells, which also results in mucosal edema, mucous production, and vasodilation. These mast cells can also produce other mediators such as prostaglandin and leukotrienes, which then lead to rhinorrhea (Cash & Glass, 2017).
This patient has a history of depression and hypertension, which is well managed by the medications she is prescribed. She is currently taking Prozac 20mg daily and Amlodipine 5mg daily. She does not take any other medications, including over the counter medications. These diagnoses do not impact her current illness. She has no past surgical history.
Review of Systems
• General: denies fever, changes in appetite or weight, skin rashes, and lesions.
• HEENT: denies headaches, loss of hearing, tinnitus, ear discharge, photophobia, changes in vision, epistaxis, and sore throat. Does report ear fullness, cough, itchy eyes, and rhinorrhea as described in HPI.
• Cardiovascular: denies chest pain, dizziness, palpitations, and swelling of extremities.
• Respiratory: denies shortness of breath, dyspnea, and wheezing.
Physical Examination
• Vital signs: temperature 98.7, blood pressure 122/69, heart rate 72 bpm, respirations 18, 99% on room air, weight 182 pounds
• General: A&Ox3, no acute distress, well nourished, steady gait, erect posture
• HEENT: Normocephalic, atraumatic; mild frontal and maxillary sinus pressure noted during palpation; bilateral canals patent without erythema or edema; right tympanic membrane dull in appearance, bulging, and intact, no injection noted; left tympanic membrane pearly gray in appearance, intact, and noted at the 7 o’clock position without injection or bulging; conjunctiva slightly injected and watery; moderate amount of clear drainage noted in bilateral nares, turbinates visible which are gray and boggy in appearance; posterior oropharynx pink in color without erythema or exudate, tonsils 1+
• Neck: non-tender; no lymphadenopathy noted; thyroid non-palpable
• Cardiovascular: S1 & S2 auscultated, heart rate regular in rhythm; no bruits, murmurs, clicks, heaves, or thrills noted; no edema
• Respiratory: Clear to auscultation in all lobes; no adventitious sounds noted
• Skin/extremities: Warm, dry, and intact; no lesions, rashes, or ulcerations noted; pedal pulses 2+ bilaterally; capillary refill <3 sec in upper and lower extremities
• Neuro/Psych: appropriately dressed for the weather, pleasant mood, well-groomed
This patient was started on Claritin 10mg, 1 tablet PO daily, #30, 3 refills. She was also started on Nasonex 50mcg/spray, 2 sprays in each nostril daily, dispense one bottle, 3 refills. She should follow up within 2-3 weeks or earlier if symptoms worsen after 3-4 days. If she does not respond to these medications or if symptoms continue despite being on medication, a referral to an allergist may be warranted (Cash & Glass, 2017). Some contemporary alternative medications and treatments that can be used for allergic rhinitis are cinnamon bark, Benifuuki green tea, and Capsaicin (Bielory, 2017).
This patient presented with symptoms that could be associated with bacterial sinusitis, nonallergic rhinitis, and viral rhinosinusitis. However, the symptoms of clear rhinorrhea, itchy eyes, boggy turbinates, ear fullness, and the fact that she is afebrile leads to the diagnosis of allergic rhinitis. She also states that symptoms seem to be worse when she is outside working in the yard and she states she has a history of childhood allergies, which also is associated with allergic rhinitis (Ryan, 2016).
Evidenced based practice states that the first line treatment for allergic rhinitis is antihistamines (H1 receptor antagonists) in conjunction with intranasal steroids. After beginning treatment, the symptoms should begin to resolve after 3 days of treatment. If the patient does not respond to treatment, she should be referred to an allergist for possible immunotherapy after identifying the specific problem allergens (Cash & Glass, 2017). The only cultural or ethnical issues to consider would be relating to the contemporary and alternative medication options since some cultures would not want to try these types of treatments due to their own beliefs and practices. The patient could continue to improve the symptoms in the future by continuing to take the antihistamine that is prescribed, especially during times when outdoor allergens are increasingly present. This issue impacts the community tremendously. Many individuals react to outdoor allergens which are seasonal and become ill due to them. Allergic rhinitis can lead to other illnesses such as otitis media, which is another way that it impacts families and the community. Implications for research could include determining which antihistamine works better for certain allergens and certain individuals. There are no cultural issues involved in the proposed health promotion plan (Wallace et al., 2017).