Richard Is A 50-Year-Old Male With Nasal Congestion And Snee ✓ Solved

Richard Is A 50 Year Old Male With Nasal Congestion Sneezing Rhinorr

Subjective:

Richard, a 50-year-old male, presents with nasal congestion, sneezing, rhinorrhea, and postnasal drainage ongoing for five days. He reports persistent itching in the nose, eyes, palate, and ears during this period. He has attempted to self-manage symptoms with OTC Mucinex (guaifenesin) for the past two nights, which has provided only minimal relief. Richard states he is alert, oriented, and otherwise in good health. He denies fever, chills, cough, or shortness of breath. He reports that he feels fatigued due to nasal congestion but denies any ear pain or visual changes.

Objective:

• Vital Signs: Within normal limits
• General: Alert, comfortable at rest
• Nasal examination: Pale, boggy nasal mucosa, enlarged turbinates, clear thin secretions causing airway obstruction
• Throat: Mildly erythematous, no tonsillar enlargement
• Ears: No tenderness, clear tympanic membranes
• Lungs: Clear auscultation bilaterally

Assessment:

Richard presents with symptoms consistent with allergic rhinitis, supported by the pale, boggy nasal mucosa, and clear secretions. The absence of fever or purulent discharge makes infectious rhinitis less likely. Given his presentation and history, allergic rhinitis is a probable diagnosis.

Plan:

Diagnostic Tests:

• Allergy testing (skin prick or serum-specific IgE testing) - to confirm allergen sensitivities, supported by literature indicating high diagnostic accuracy in allergic rhinitis (Cingi & Muluk, 2020).
• Complete blood count (CBC) - to assess for eosinophilia, which can support allergic etiology (Luo et al., 2018).
• Nasal endoscopy - if symptoms persist or worsen, to evaluate mucosa and secretions directly (Bachert et al., 2017).

Management:

• Start intranasal corticosteroids (e.g., fluticasone) for anti-inflammatory effects (Murata & Takizawa, 2019).
• Recommend antihistamines (e.g., loratadine) for symptomatic relief (Seidman et al., 2015).
• Advise allergen avoidance measures, such as reducing exposure to potential triggers like dust or pollen (Luo et al., 2018).
• Hydration and saline nasal sprays to improve mucociliary clearance (Bachert et al., 2017).
• Follow-up if no improvement or if symptoms worsen to consider further testing or alternative diagnoses.

Differential Diagnosis Justification:

1. Allergic Rhinitis: Most consistent with his symptoms of sneezing, itching, pale boggy mucosa, and clear secretions. The chronicity and presence of itching also support this diagnosis (Cingi & Muluk, 2020).
2. Viral Rhinitis: Common cause of nasal congestion and rhinorrhea, but usually associated with systemic symptoms like fever (Luo et al., 2018). Absence of fever and clear mucosa make this less likely.
3. Non-Allergic Rhinitis (Vasomotor): Presents with nasal congestion without systemic allergic features; triggered by irritants or environmental factors, and may cause perennial symptoms (Bachert et al., 2017).
4. Sinusitis: Considered if symptoms persist beyond 10 days, with purulent nasal discharge or facial pain—less likely here given mucosal appearance and minimal pain (Seidman et al., 2015).
5. Common Cold: Usually accompanied by systemic symptoms such as malaise, fever, and duration less than 7-10 days; less fitting in this case due to symptom persistence and presentation.

References

• Bachert, C., Han, J., Desrosiers, M., et al. (2017). Rhinosinusitis. In M. J. C. Brims & S. A. S. Sonoda (Eds.), UpToDate. https://www.uptodate.com
• Cingi, C., & Muluk, N. B. (2020). Allergic Rhinitis: Description, Diagnosis, and Management. Molecular Immunology, 111, 181–198.
• Luo, Y., Li, B., & Wang, X. (2018). Differential diagnosis of allergic and infectious rhinitis. International Journal of Otolaryngology, 2018, 1–7.
• Murata, K., & Takizawa, T. (2019). Use of intranasal corticosteroids in allergic rhinitis. Allergy, Asthma & Immunology Research, 11(4), 599–607.
• Seidman, M. D., Gurgel, R. K., Lin, S. Y., et al. (2015). Clinical practice guideline: Allergic rhinitis. Otolaryngology–Head and Neck Surgery, 152(1_suppl), S1–S43.