Pediatric Allergy & Immunology Assessment

Dear Dr.,

Thank you for referring this pleasant patient for allergy/immunology assessment. The patient was seen in person.

Subjective
History of Presenting Illness:
1. Nasal congestion and frequent nose clearing: The patient has had ongoing nasal congestion and frequent "snorking" (nose clearing) for several weeks. There is a history of intermittent use of a prescription nasal spray for 8 weeks, which was then stopped. Symptoms increased after stopping the spray, with the patient reporting being "stuffed up" frequently. There was one episode of yellow nasal discharge, which improved after a single nasal rinse, but there was no significant improvement overall after the rinse. No true allergies have been identified, but a sensitive nose is suspected. Sinus pain was previously reported. The patient has not reported shortness of breath or fever.

2. Environmental factors: The patient has exposure to dust and clutter at home. There was a recent move, with increased efforts at cleaning and dust control. No exposure to smoke was reported.

Stinging Insect Reactions:
None reported.

Past Medical History:
healthy

Medications:
- Prescription nasal spray (recently ran out, previously used for 8 weeks)
- Saline nasal rinse (used once)

Family History:
No family history of atopy.

Social and Environmental History:
The patient is exposed to dust and clutter at home. There has been a recent move, with increased cleaning and dust control efforts. No smoke exposure reported.

Physical Examination:
Head and Neck: oropharynx was clear, tonsils 1+/4, nose with slight congestion and minimal mucus, neck without lymphadenopathy or tenderness

Assessment and Plan:
1. Non-allergic rhinitis with nasal congestion. The patient has a sensitive nasal mucosa, likely triggered by dust and environmental irritants. Adenoid is not enlarged (40%), and there is no surgical indication. The plan is to restart the prescription nasal spray for a minimum of 3 weeks of continuous use, with extension if symptoms persist. Saline nasal rinses are to be continued as adjunct therapy. Environmental control measures were emphasized, including reducing dust, decluttering the bedroom, washing stuffed animals weekly, and using dust covers on bedding. Monitor for symptom resolution and continue the spray until symptoms resolve and for 2 additional weeks. No surgical intervention is indicated.

2. Environmental management. Maintain rigorous dust control in the home and bedroom. Limit stuffed animals to one in the bedroom, rotating as needed. Encourage regular cleaning and decluttering.