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CASE Allergic Rhinitis

1. A 9-year old male patient presented with complaints of continuous colds, sneezing, itchy nose, mucus, and nasal obstruction for the past week. 2. On physical examination, the patient showed signs of allergic rhinitis including edema and lividity of the nasal mucosa. 3. The working diagnosis was suspected allergic rhinitis. Further workup including RAST testing and nasal swab for IgE was recommended to confirm the diagnosis. Therapy included patient education, avoiding allergens, pharmacotherapy with antihistamines and decongestants, and possible immunotherapy.

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rizgah jawas
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438 views5 pages

CASE Allergic Rhinitis

1. A 9-year old male patient presented with complaints of continuous colds, sneezing, itchy nose, mucus, and nasal obstruction for the past week. 2. On physical examination, the patient showed signs of allergic rhinitis including edema and lividity of the nasal mucosa. 3. The working diagnosis was suspected allergic rhinitis. Further workup including RAST testing and nasal swab for IgE was recommended to confirm the diagnosis. Therapy included patient education, avoiding allergens, pharmacotherapy with antihistamines and decongestants, and possible immunotherapy.

Uploaded by

rizgah jawas
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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CASE DISCUSSION

ALLERGIC RHINITIS

Supervisor
dr. H. Oscar Djauhari, Sp. THT-KL
Presentant
Rizgah M Jawas 2012.730.091
Army Oktavianto 2012.730.011
Yuka Puspita A. 2012.730.110

Clinical Rotation
Otolaryngology, Head and Neck Department
Medical Faculty of Muhammadiyah Jakarta University Syamsudin, S.H.
Regional General Hospital, Sukabumi
Period of 13th June 17th July 2016
PATIENTS IDENTITY

Name
Age
Gender
Race
Address
Weight
Height

: NK
: 9 years old
: Male
: Sundanese
: KP. Cihereus, Cibadak
: 35 kg
: 140 cm

ANAMNESIS
Chief complaint : unconsciosness

Additional complaint : Continous Colds

Sneezing

Itchy nose

Mucus liquid

Nasal Obstruction
History of present illness :
Son, 9 years old, came to the hospital with complaints continuous colds
within one weeks ago on his nose. The patient also complaints about Itchy
nose, sneezing, mucus liquid, and nasal obstruction since 3 days ago.

History of past illness

The patient has a history of house dust allergy before.


History of family disease
The family has a history of allergy
Physical Examination
1. General status
General appearance
Consciousness
Heart rate
Respiration rate
Temperature
2. ENT Status

Ear

: moderately ill
: Compos mentis
: 88 times per minute
: 16 times per minute
: 36,5 oC

Right ear

Auricle

(-)
Canalis Acousticus Externa

: hyperemic (-), oedema


: hyperemic (-), mass (-),
Discharge (+) minimal, yellowish
and purulent, cholesteatoma (-),

Tymphanic membrane

Whisper test

Left ear

Odorous smell, laceration(-)


: marginal perforation, light
reflex (+)
: Normal.

Auricle

: hyperemic (-), oedema

(-)

Canalis Acousticus Externa

: hyperemic (-), mass (-),


discharge (-), cholesteatoma (-),
laceration (-)

Tymphanic membrane

: intact, bulging (-), light reflex


(+)

Whisper test

: Normal.

Nose
Inspection nose
Right Nose

: Allergic salute, allergic crease

Mucous membrane

: edema (+), livid (+)

Concha

: eutrophy

Cavum

: discharge(-),mass (-),crust (-),bleeding


(-), secretion (+)

Septum

Left nose

: normal

Mucous membrane

: edema (+), livid (+)

Concha

: eutrophy

Cavum

: discharge(-),mass (-),crust (-),bleeding


(-), secretion (+)

Septum

: normal

Mucous membrane

: hyperemic -/-, oedem -/-

Arcus anterior

: uvula in the middle, mass -/-

Pharynx

: normal pharyngeal arch, hyperemic (-)

Tonsil

: T1-T1, hyperemic (-)

NPOP

Neck

: lymphadenopathy -/-

3. Facial Nerve Examination (right / left)


Facial expression
: symmetrical
Raising eyebrow
: difficult / normal
Closing eyes
: left behind / normal
Smiling
: left behind / normal
Working diagnosis
Suspect allergic rhinitis
Workup
In vitro : RAST (Radio Allergo Sorbent Test)
To make sure diagnosis allergic rhinitis should be fined IgE in nasi cavity with

a swab and anatomic pathology examination


Skin test

Therapy
Patient education
Avoiding allergens and irritants
Pharmacotherapy
antihistamines
decongestants
intranasal corticosteroids
Immunotherapy

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