Sever Allergic Rhinitis Testing

Discussion: Assessing the Ears, Nose, and Throat
As Motomura et al. (2016) point out, “pale nasal mucosa is a typical clinical finding in subjects with severe allergic rhinitis” (p. 220). In the case of Richard, the 50 year old male who has presented with nasal congestion, sneezing, rhinorrhea, and postnasal drainage—in other words, an itchy nose, eyes, palate and ears which have bothered him for 5 days—the symptoms that Richard is exhibiting are very likely the effect of severe allergic rhinitis or what is commonly known as hay fever.
As hay fever routinely occurs in the summer and spring months when pollen and mold are in the air and can be highly concentrated in areas depending on geography and weather, it is important to take note of external factors—the environment—that might be impacting Richard over the past week. A history of his outdoor activities, where he lives, whether he has been exposed to pollen or mold, to which his body could be having an exaggerated reaction should all be information that the nurse obtains over the course of questioning.
Quillen and Feller (2006) state that “allergic rhinitis, the most common type of rhinitis, generally can be differentiated from the numerous types of nonallergic rhinitis through a thorough history and physical examination” (p. 1583). The history of the patient should therefore be obtained and a physical examination of eyes, ears, nose, throat, chest and skin should be conducted.
The diagnosis for the patient is severe allergic rhinitis and this can be confirmed through allergen testing. The physical examination leads to this supposition. Differential diagnoses include: non-allergic rhinitis, acute sinusitis, and deviated septum. Examination and testing for pathogens and/or bacterial infection along with nasal passage should be conducted. Information about the patient’s background, Soc Hx, and Fam Hx is needed. Questions to ask the patient include: Have you been outdoors recently, walking, hiking, gardening, etc? What is your workplace environment like? Do you have a history of allergies popping up at this time of the year? Are allergies in your family? What are you lifestyle habits? Have you been taking any recreational drugs?
Episodic/Focused SOAP Note
Patient Information: R. 50 M N/A
S.
CC (chief complaint): “itchy eyes, nose, throat, ears for 5 days”
HPI: 50 year old R male
Location: head
Onset: 5 days ago
Character: itchiness in eyes, nose, throat and ears
Associated signs and symptoms: pale, boggy nasal mucosa w/ clear thin secretions, enlarged nasal turbinates; lungs are clear; tonsils not enlarged; throat mildly erythematous
Timing: bothersome especially at night
Exacerbating/relieving factors: Mucinex hardly helping; presses/rubs bridge of nose to relieve pressure
Severity: unknown
Current Medications: Mucinex OTC
Allergies: unknown—an allergy test should be conducted; patient may need allergen avoidance treatment; an allergen-specific immunoglobulin E antibody test should be given (Quillen & Feller, 2006)
PMHx: unknown—ask patient whether he has received any immunizations
Soc Hx: unknown—ask patient about his hobbies, where he works, whether he spends time gardening, outdoors, etc., family history, living environment, support system, drug use, etc.
Fam Hx: unknown—ask patient whether there is history of allergies in family
ROS:
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclera; eyes are itchy and red; Ears, Nose, Throat: sneezing, congestion, sore throat.
SKIN: unknown--examine
CARDIOVASCULAR: unknown
RESPIRATORY: lungs are clear but nasal drainage is present
O.
Physical exam: enlarged nasal turbinates, which obstruct airway flow but his lungs are clear. His tonsils are not enlarged but his throat is mildly erythematous. He has nasal congestion, sneezing, rhinorrhea, and postnasal drainage.
Diagnostic results: unknown—perform allergen test
A.
Differential Diagnoses:
· severe allergic rhinitis is the presumptive diagnosis—occupational rhinitis, perennial rhinitis or seasonal rhinitis will need to be determined based on history of the patient and background;
differential diagnoses include:
· Nonallergic rhinitis
· Atrophic rhinitis, chemical or irritant-induced rhinitis, or drug induced rhinitis, which may be caused by antihypertensive drugs, aspirin, anti-inflammatory drugs or rhinitis medicamentosa (Quillen & Feller, 2006)
· Acute sinusitis—less than 2 weeks, may be due to infection (Meltzer et al., 2004); test for infection
· Chronic sinusitis—longer than 12 weeks; rule out if patient attests to onset only lasting 5 days and nothing prior; test for bacterial infection otherwise (Meltzer et al., 2004)
· Viral rhinosinusitis—less than 2 weeks; perform clinical test
· Infectious mononucleosis—accompanied by fatigue, fever; dismiss if these symptoms are not present
· Nasal polyps—examine for overgrowths of mucosa
· Deviated nasal septum—examine for obstruction, rupture of septum; may be treated with surgery
· Adenoidal hypertrophy—lateral X-ray
· Cerebrospinal fluid rhinorreha—nuerological examination
· Ciliary dyskinesia syndrome—congenital; consult patient history

References
Meltzer E., et al. (2004). Rhinosinusitis: establishing definitions for clinical research and
patient care. J Allergy Clin Immunol, 114, 155-212.
Motomura, C., Odajima, H., Yamada, A., Taba, N., Murakami, Y., & Nishima, S. (2016).
Pale nasal mucosa affects airflow limitations in upper and lower airways in asthmatic children. Asia Pacific Allergy, 6(4), 220-225.
Quillen, D. & Feller, D. (2006). Diagnosing Rhinitis: Allergic vs. nonallergic.
American Family Physician, 73(9), 1583-1590.