Patient is a 31 year old white male
Chief of Complaint: Came into the office for an evaluation of his allergic rhinitis.
History of Present Illness: Did not report any history of present illness.
Allergies: allergic rhinitis.
Medications: Patient is on Flonase nasal spray and Zyrtec daily for his allergic rhinitis. A review of his medical record reveals to you this â€˜shotâ€™ has been a steroid injection.
Social History: He owns his own business â€˜Dr. Vinylâ€™ where he specializes in repairing vinyl in automobiles, boats, recreational vehicles, etc.
Family History: No family history reported
Health Maintenance Activities: Exposure to the smell of several of the products he works with has resulted in dissatisfactory management of his typical allergic rhinitis. On numerous occasions over the last decade he has requested and been given an â€˜allergy shotâ€™. A review of his medical record reveals to you this â€˜shotâ€™ has been a steroid injection.
Review Of systems: Patient has allergic rhinitis
Constitutional â€“ BP 122/74, P 76, R 18
Assessment: Based on the patientâ€™s subjective data, the patient has recurrent allergic rhinitis.
Having the patient take antihistamines can help with his allergic rhinitis. Antihistamines can help the patient with a runny nose, itchy eyes, and sneezing. Antihistamines such as diphenhydramine can be used to help the patient with his allergic rhinitis (Akhouri & House, 2023). However, itâ€™s important to note that there are common adverse effects to expect when taking this medication, such as tachycardia, bladder remtion, dry mouth, and more (Akhouri & House, 2023). Another medication that we can give the patient is corticosteroids. Intranasal corticosteroids can help with congestion and inflammation (Akhouri & House, 2023). They do this by shrinking the inflamed nasal tissues through its vasoconstricting properties. This is a more common approach to allergic rhinitis as it has less adverse effects.
Itâ€™s important to educate the patient on the type of medication that he will take. Itâ€™s crucial that the patient knows about the potential side effects, how to use/take the medication, and how to know if it is effective. Itâ€™s also important for the patient to avoid triggers that can make his allergic rhinitis worse.
I would encourage the patient to see his primary healthcare provider again if he feels like the medication is not working or if he is experiencing side effects that affect his daily life. If none of those things occur, I would still encourage the patient to come back annually to get checked out.