Allergic Rhinitis - English

In person appointment 30 min **ID:** 123456 **RFC:** 7891011 **Ref MD:** Dr. John Smith **PMHx:** - Hypertension - Hyperlipidemia **Allergic Hx:** - Asthma (Most recent PFT: FEV1 (2.5 L / 80%), FVC (3.0 L / 85%), ratio (83%)) - Rhinosinusitis - Obstructive sleep apnea - Pollen food syndrome / food allergy - Atopic dermatitis - Medication allergy: Penicillin **FHx allergy:** - Mother: Allergic rhinitis - Father: Asthma **Home environment / social:** Occupation: Gardener with the following exposures: pollen, dust Patient lives in a: House Home has issues with: mold, dust Pets: cat, dog Secondhand smoke exposure: None **Habits** Smoking: Non-smoker EtOH: Social drinker Drugs: None **Meds:** The patient has private medication insurance **HPI:** Symptoms began 2 years ago Symptoms are related to seasons The most pertinent symptoms are: - Nasal congestion, rhinorrhea, post nasal drip, nasal pruritus, sneezing - Ocular itch, conjunctivitis No loss of smell, no sinusitis, no asthma They have affected the patient’s quality of life: fatigue, sleep disturbance, learning / attention issues, absenteeism **O/E:** General: Well-appearing Nasal mucosa: pale and swollen turbinates, clear rhinorrhea. Polyps were not visualized with the otoscope Chest: good air entry bilaterally, clear Skin: Atopic dermatitis on arms **Skin prick testing:** Inhalants: Positive for dust mites, cat, dog; Negative for horse Trees: Positive for birch, oak; Negative for maple Grasses: Positive Weeds: Positive for ragweed; Negative for plantain pollen Dust Mites (DP, DF): Positive Animals: Positive for cat, dog; Negative for mouse Molds: Negative Foods: Positive for: Peanuts Negative for: Milk, eggs **Other Ix ** - None **Diagnosis:** Seasonal allergic rhinoconjunctivitis **Plan** **Environmental measures discussed.** **Pollen:** Avoid exposure on days of high pollen counts e.g. closing windows and avoiding going outdoors on those days. **Dust mite:** protective covers, washing bedding in hot water every 1-2 weeks, consider HEPA filter, decreasing relative humidity 35 - 45%. **Molds:** Face mask when gardening, eliminating sources of moisture **Cockroach:** sealing all food sources, food debris removal, thorough home cleaning **Animals:** remove from environment and out of bedroom, HEPA filter **Irritants:** avoid exposure to strong smells such as tobacco, perfume, chlorine An educational handout was given to the patient. **Pharmacological management** - Intranasal corticosteroid - Antihistamine eye drops - Oral 2nd generation antihistamine - Sinus rinse DIE **Allergen immunotherapy** Risks and benefits discussed. Patient did not have any major contraindications such as history of severe local reaction to sublingual immunotherapy, severe systemic reaction to any immunotherapy, severe / uncontrolled asthma, eosinophilic esophagitis, hypersensitivity to the preparation, or recent cardiac events or uncontrolled hypertension. Patient signed consent to start sublingual immunotherapy with Grastek. First dose was given today in the office. Patient was discharged after 30 minutes of observation with no major adverse effects. Instructed to continue every day for the duration of the season. A handout was given for home instructions. **Follow up** in 6 months