Snoring

Patient is 5-year-old boy here with his mother and older brother to discuss his problems of nasal drainage. He has always had nasal congestion and mother thinks that it is starting to get worse over he gets. She states that he has nasal symptoms including sneezing, itching of the nose, nose rubbing, clear nasal discharge, postnasal drip, nasal stiffness, mouth breathing, frequent throat clearing, sore throat, hoarseness, itching inside ears, and snoring. These seem to happen everyday throughout the year. The worst time in the year for him is spring and early summer and then in the fall. He has had some frequent infections in the past including sinus infection. He also has frequent ear infections five within the last year and he has needed ear tubes placed in the past. He also is having multiple tonsillitis infections, which caused him to have his tonsils removed at age two. He currently has strep throat infection that he is using antibiotics for today although he does not have tonsils. He also has frequent bad cold and he has had two bouts of pneumonia in the past, none of them have required IV antibiotics or hospitalization.

He has tried using Flonase, Zyrtec, and Singulair since he was two years old. He has been off the Zyrtec, Flonase, and Singulair for the last two weeks before this appointment and mother noticed that he did not have severe increase in his symptoms. She does feel that Singulair helps with his asthmatic problems before. So, she would like to continue Singulair. She states that these medications provide moderate relief for her son.

He also complains of eye symptoms including itching, redness, tearing, light hurting his eyes, yellow discharge from eyes, eyelid swelling, and eyelid irritation. This happens a lot of the time.

He also has had a history of wheezing since his age two; mild-to-moderate, seems to occur as the season changes usually associated with cough. He uses Singulair, ProAir, and has a nebulizer if he needs it. He seems to need his inhaler about four to five times a year. ProAir does give some relief with his symptoms. He complains of frequent coughing spells, recurrent night cough, coughing on exertion, coughing on wheezing, and coughing with lying down. The mother has not noticed that this is associated specifically with sicknesses and thinks he may be allergically triggered. He did have a chest x-ray done within five years. Last one was in 2014 at Primary Health.

He also has some atopic dermatitis that he has always had mostly in his legs, back of knees, and buttocks and body. The mother uses Aquaphor after showers and that seems to help most of his symptoms. She also has a triamcinolone ointment for rash patches to help reduce his outbreaks. He currently is doing pretty well with his dermatitis. She states that it is mostly worse in the wintertime. He has never been evaluated for allergies in the past.

ASSESSMENT:
1. Allergic rhinitis versus mixed rhinitis.
2. Intermittent asthma.
3. Allergic conjunctivitis.
4. Concern for immunodeficiency.
5. Snoring.

PLAN:
1. At this time, we will continue with Singulair, ProAir, and a nebulizer for his intermittent asthma symptoms. This seems to work well for him.
2. Since mother has not noticed that Flonase and Zyrtec have been helping much and he is still non-allergic today, she would like to try to not use Flonase and Zyrtec for the next week or two and see if this makes a difference and if he has increased symptoms. This will help to further verify if he has allergic source of his symptoms even though the testing was quite negative today.
3. We will do a blood workup for immunodeficiency, CBC with differential, immunoglobulin qualitative and quantitative, lymphocyte subset panel, anti-pneumococcal titer, anti-diphtheria titer, anti-tetanus titer, and sweat chloride. This will help without any other abnormalities in his immune system causing some of these frequent infections.
4. We will follow up in two to three weeks once we get lab results back to further discuss patient symptoms.

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