Case Study Of A Patient With Nasal Congestion

Subjective Data

Chief complaint: a persistent runny nose for three weeks

History of presenting complaint: W.R is a 76-years old American female complaining of a persistent runny nose for three weeks associated with nasal drainage, clearing of the throat, and occasional nasal congestion on waking up. The patient states that the trigger of these symptoms is spring season pollination. She also reports having an itching nose, eyes, and palate, tearing, red eyes, drowsiness, fatigue, and eye swelling. She denies chest pain, coughing, wheezing, sputum production, fast breathing, and shortness of breath.

Past medical history: the patient has had osteoarthritis, diabetes mellitus, and hypertension. She has a positive history of hospitalization in her youthful years due to diabetes keto-acidosis. She denies a history of cancer, mental illness, and asthma.

Immunization: her immunization schedule is up to date. Her last H. influenza and the pneumococcal vaccine was three months ago.

Past surgical history: she has had two cesarian sections each five years apart.

Allergies: the patient develops heaves and running nose when exposed to pollen, dust, or fur and relieves by taking an antihistamine. She denies food and drug allergy.

Current medication: Lantus insulin 28Iu SC in the morning and 14Iuin in the evening for glycemic control. Aspirin 81mg per oral once daily for pain. vitamin D and calcium supplementation for osteoarthritis. Hydroxyzine 50mg PO PRN for allergic reaction.

Family history: the patient is the thirdborn in a family of five. Her father passed on at the age of 80years due to COPD and her mother passed on at the age of 67years years due to a heart attack. Her elder sister passed on at the age of 70years due to status asthmaticus. Her elder and younger brother are living with hypertension and asthma. She denies a family history of cancers and mental illness.

Social history: the patient is widowed. She has two children who live in another state. She is a retired lecturer. She recently moved into an independent living center because of loneliness and to get help for activities of daily living. She enjoys reading and singing in the church choir. She denies the use of alcohol and smoking. She does not engage in physical exercise because of joint pain. she takes food with low sodium to control her blood pressure.

Reproductive history: the patient is in her menopausal period. Her last menstrual flow was 25years ago. Her menarche was at the age of 15 years. She has had a regular 28days cycle with three days of moderate flow. She denies a history of dysmenorrhea and pre-menstrual syndrome. She denies the use of contraception. She has two children born via the cesarian section due to breech presentation. She has had one sexual partner in her lifetime. She denies sexually transmitted infections. Her last pap smear was negative.

Review Of Systems

General: The patient denies fever, chills, rigors, weight loss, and weight gain

Cardiovascular system: the patient denies syncope, dizziness, paroxysmal nocturnal dyspnea, palpitations, tachycardia, orthopnea, and edema.

Gastrointestinal system: she denies bloating, abdominal pain, diarrhea, constipation, nausea, heartburn, loss of appetite, reflux, vomiting,

Genitourinary system: she denies dysuria, polyuria, hematuria, urine incontinence, urgency, vaginal bleeding, vaginal discharge, and lower abdominal pain.

Musculoskeletal: she complains of joint pain and stiffness. However, she denies muscle spasms and numbness.

Neurological system: the patient denies facial droop, numbness, of extremities, reduced reflexes, muscle weakness, loss of consciousness, and convulsions.

Psychiatric: the patient states that she feels lonely after her husband passed on. She denies anxiety, depression, impaired concentration, and psychosis.

Objective Data

General: the patient is calm and oriented. She has no cyanosis and edema.

Vitals: Blood pressure is 130/84 mmHg, temperature 98.6, pulse 78, respiratory rate 20. WT: 70kgs, HT 1.51m, and BMI 30kg/m².

HEENT: the nose is erythematous with swollen nasal turbines and has thin watery secretions. There is no septum deviation or perforation, nasal polyps, and nasal tumors. The eyes are red and watery. The ears are erythematous with no swelling and secretions. The mouth cavity is moist and pink. There is no pharyngeal swelling.

Skin: the facial skin is pink and erythematous. There is no rash or bruises.

Respiratory examination: the chest has symmetrical expansion when breathing. There is no mass, scars, erythematous skin, and swelling. There is a resonant percussion note. There are transmitted sounds in the lung zones. However, there is no rhonchi, stridor, crackles, or wheezing.

Cardiovascular system: the heart is normative at the 5^th ICS. Normal sounds S1 and S2 are present without murmurs and pericardial rub. The peripheral arterial pulse is present at a normal volume, regular rate, and rhythm. There are no palpable bruits.

Abdominal examination: the abdomen is round, has no scars, obvious mass, and striae. The bowel sounds are present in the four quadrants. There is a tympanic percussion note with no shifting dullness. The abdomen is soft with no areas of tenderness.

Diagnostic tests and findings

Total eosinophil count and total serum IgE are specific for allergic rhinitis. An allergy skin test helps determine IgE-mediated sensitivity (Wang, et al, 2018). Face and head radiographs evaluate for possible structural abnormalities like adenoid hypertrophy and sinusitis. Face CT scan helps evaluate acute and chronic sinusitis. Complete blood count with differentials to rule out infections. Throat swab for culture to rule out bacteria rhinosinusitis.

Assessment

Primary Diagnosis

• Allergic rhinitis J30.9: Allergic rhinitis is the inflammation of the mucus membrane of the nose, middle ear, sinuses, and the eyes. The allergic reaction is an IgE-mediated hypersensitivity after exposure to allergens (Zhang, Y., & Zhang, L. 2019). The mediators cause the release of mast cells and histamine. The interaction of these two causes rhinorrhea, sneezing, itchiness, redness, tearing, swelling, post nasal drip, increased secretions, and plasma exudation. Vasodilation of the mucus membrane causes nasal congestion and increased pressure. The persistence of these mediators leads to the production of inflammatory cells, increasing nasal congestion and mucus secretion. The inflammatory response causes fatigue, drowsiness, and malaise. The patient was exposed to pollen at the beginning of spring three weeks ago. Pollen triggered the IgE mediators and inflammatory cells hence her symptoms of nasal drainage, clearing of the throat, and occasional nasal congestion on waking up.

Differential Diagnoses

• Acute sinusitis J01.90: Acute sinusitis is the inflammation of paranasal sinuses associated with concurrent rhinitis. It is common in females above 64years old. The concurrent rhinosinusitis may be caused by bacterial, fungal, and viral infections. The presenting symptoms are a headache in the temporal region, facial fullness, hyposmia, blocked nose, redness of the nose and the eyes, persistent coughing and laryngeal irritation, nasal congestion, fever, and ear pressure (DeMuri, et al, 2019). The patient presents with similar symptoms nasal drainage, clearing of the throat, and occasional nasal congestion on waking up. However, it is not the actual diagnosis because the patient denies coughing, fever, headache, ear pain, and facial fullness. A nasal cytology test is appropriate to rule out allergic rhinitis and nasal polyps.
• Upper respiratory tract infection J06.9: An upper respiratory tract infection is a self-limiting infection of the nasopharynx. The pathogens causing upper respiratory tract infection are bacteria, viruses, and fungi. The most common bacteria agent is group A streptococcus. Viral agents are rhinoviruses, coronaviruses, adenoviruses, and coxsackieviruses. Causes of upper respiratory tract infections are obstruction from allergic rhinitis, smoking, contact with people with upper respiratory tract infections, trauma to the airway, and immunosuppression. Commonly, I school-going children younger than 5 years and elderly patients above 60. The clinical signs and symptoms are nasal mucosal erythema, nasal discharge, foul breath, fever, cervical lymphadenopathy, sore throat, muffled dysphonia, dry cough, tonsillar hypertrophy, fatigue, and sniffing posture (Vorilhon, et al, 2019). This is not the patient’s diagnosis because she denies fever, coughing, and headache. She has no history of contact with a patient with an upper respiratory tract infection.

Plan

Pharmacological treatment

1. Mometasone nasal spray twice daily to relieve inflammation and nasal congestion
2. Montelukast 10mg PO once daily to prevent the action of mast cells and eosinophils.
3. Sublingual immunotherapy to prevent recurrent allergic rhinitis

Patient education

Observe environmental control measures like reducing outdoor exposure and keeping the doors and windows closed during the season (Seedat, R. Y. 2019). Thorough vacuum cleaning of rugs and carpets to get rid of pollen and dust.

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References

DeMuri, G. P., Eickhoff, J. C., Gern, J. C., & Wald, E. R. (2019). Clinical and virological characteristics of acute sinusitis in children. Clinical Infectious Diseases, 69(10), 1764-1770. https://doi.org/10.1093/cid/ciz023

Seedat, R. Y. (2019). Environmental control of outdoor allergens. Current Allergy & Clinical Immunology, 32(1), 12-14. https://hdl.handle.net/10520/EJC-15b23dc43b

Vorilhon, P., Arpajou, B., Vaillant Roussel, H. et al. Efficacy of vitamin C for the prevention and treatment of upper respiratory tract infection. A meta-analysis in children. Eur J Clin Pharmacol 75, 303–311 (2019). https://doi.org/10.1007/s00228-018-2601-7

Wang, X., Du, K., She, W., Ouyang, Y., Sima, Y., Liu, C., & Zhang, L. (2018). Recent advances in the diagnosis of allergic rhinitis. Expert review of clinical immunology, 14(11), 957-964. https://doi.org/10.1080/1744666X.2018.1530113

Zhang, Y., & Zhang, L. (2019). Increasing prevalence of allergic rhinitis in China. Allergy, asthma & immunology research, 11(2), 156-169. https://doi.org/10.4168/aair.2019.11.2.156