A 28-year-old female presents with complaints of a runny nose and itchy eyes. She reports that these symptoms began approximately 9 days ago and typically occur every spring, lasting for six to eight weeks

QUESTION

A 28 year old female comes in complaining of a runny nose and itchy eyes. States runny nose, itchy eyes, and ears felt full approximately 9 days ago. “I get this every spring and it seems to last six to eight weeks”. Describes nose is runny with clear mucus. Sneezes on and off all day. Eyes itch so bad she just wants to scratch them out, sometimes feels a tickle in her throat and ears feel full and sometimes pop. Last year took Claritin with relief. Charlotte is alert and oriented. He has pale, boggy nasal mucosa with clear thin secretions and enlarged nasal turbinates, which obstruct airway flow but his lungs are clear. His tonsils are not enlarged but his throat is mildly erythematous. Use the Episodic/Focused SOAP Template and prepare an episodic/focused note about the case above using the episodic/focused note template . Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis and justify why you selected each.

ANSWER

Subjective: A 28-year-old female presents with complaints of a runny nose and itchy eyes. She reports that these symptoms began approximately 9 days ago and typically occur every spring, lasting for six to eight weeks. The patient describes her nose as constantly runny with clear mucus and experiences frequent sneezing throughout the day. She also complains of intense itching in her eyes and a sensation of fullness in her ears, which occasionally leads to popping. The patient mentions taking Claritin last year and finding relief. She is alert and oriented.

Objective: Upon examination, the patient exhibits pale, boggy nasal mucosa with clear, thin secretions. Nasal turbinates are enlarged, obstructing airflow, but lung auscultation reveals clear breath sounds. Tonsils are not enlarged, although the throat appears mildly erythematous.

Assessment

Allergic rhinitis: The patient’s symptoms of a runny nose, itchy eyes, and seasonal occurrence suggest allergic rhinitis. The presence of pale, boggy nasal mucosa with clear secretions further supports this diagnosis. The response to Claritin in the past also indicates an allergic component.

Seasonal allergies: The patient’s symptoms occurring during spring and lasting for several weeks align with seasonal allergies. The characteristic nasal symptoms, itching, and episodic nature of the condition further support this diagnosis.

Hay fever: The patient’s symptoms of sneezing, itchy eyes, and nasal congestion are consistent with hay fever, which is commonly caused by allergens such as pollen.

Allergic conjunctivitis: The patient’s complaint of intense eye itching suggests allergic conjunctivitis, which often accompanies allergic rhinitis. The presence of clear nasal secretions and boggy nasal mucosa supports the allergic etiology.

Environmental allergies: Considering the patient’s symptoms occur during spring and are triggered by specific environmental factors, environmental allergies should be considered as a possible diagnosis. The patient’s history of experiencing similar symptoms annually further supports this hypothesis.

Diagnostic Tests

Skin prick test: A skin prick test can identify specific allergens that trigger the patient’s symptoms, helping confirm the diagnosis of allergic rhinitis and guide further management.

Allergen-specific IgE blood test: This test measures the levels of specific IgE antibodies in the blood, providing information about the patient’s sensitivity to particular allergens and supporting the diagnosis of allergies.

Nasal endoscopy: A nasal endoscopy may be considered to assess the degree of nasal congestion, visualize the nasal passages, and identify any structural abnormalities.

Complete blood count (CBC): A CBC may be performed to rule out other underlying conditions and assess the patient’s overall health status.

Pulmonary function tests: If warranted, pulmonary function tests can be conducted to evaluate lung function and determine if there is any underlying respiratory involvement.

In conclusion, based on the patient’s history, symptoms, and examination findings, the most likely diagnosis is allergic rhinitis, possibly due to seasonal or environmental allergies. Further diagnostic tests such as skin prick testing and allergen-specific IgE blood tests can be utilized to confirm the diagnosis and identify specific allergens. It is important to consider these differential diagnoses and conduct appropriate diagnostic evaluations to provide the patient with accurate treatment and symptom management.