Episodic Visit: Adolescent Focused Note (Ages 13-17)

Patient Information:

Initials: K.M.   Age:   17 years           Sex:    F          Race: Caucasian

S.

CC (chief complaint): “I have had a sensation of irritation and itching in my eyes since last Sunday. I have also had pain in my right ear since yesterday and a cough accompanied by throat pain for a week. Lastly, I had a nose bleed today as well as several episodes of headaches.”

HPI: The patient is a 17-year-old Caucasian adolescent presenting with the above symptoms. She has a past history of the same as she suffers from allergy to strong smells, dust, and the cold. The onset of the symptoms started a week ago and they are located in the respiratory system, the eyes, and in the cranial sinuses. The total duration of these symptoms has been about seven days. The symptoms include rhinorrhea, nasal and chest congestion, headaches, sinus pain, malaise, and epistaxis. They are characteristically sudden, unrelenting, and recalcitrant. The symptoms are aggravated by strong smells like that of perfumes, cold wind currents (such as those coming in from open windows), and dust particles. Symptomatic relief occurs when she takes medications such as Zyrtec and albuterol. The timing of the symptoms is anytime day or night. The patient gives the symptoms a severity rating of 7/10.

Current Medications: She is currently taking the following medications.

1. Albuterol (Salbutamol) 2 puffs q 4-6 hours PRN.
2. Cetirizine (Zyrtec) 10 mg orally O.D.

• Acetaminophen or APAP (Paracetamol) 1 g orally PRN.

She has used albuterol (Salbutamol) for years to combat acute shortness of breath and wheezing as a rescue inhaler (Papi et al., 2020; Ramsahai et al., 2019). The cetirizine is used to combat allergy symptoms and has been used for six months. Lastly, she is also on over-the-counter (OTC) APAP for the sporadic headaches.

Allergies: She is allergic to dust, strong smells, and cold breezes or weather.

PMHx: She has received all her immunization doses from childhood up to the present time without missing. She has no history of any past major illness or surgeries; although she was born allergic to dust, strong smells, and cold. Because of her allergies, she has in the past suffered colds, coughs, and headaches.
Soc & Substance Hx: The patient is a student in high school in grade 11 currently. She lives with her father and mother as well as her two other siblings. Her hobbies include reading, riding the bicycle, cooking, watching movies on Netflix, and traveling. She denies ever using any drugs or substances such as alcohol and tobacco. She states that she also does not have any friends that use drugs or substances at present. Their flat has smoke detectors and all amenities are available in the neighborhood. She does not yet have a driving license but always makes sure she has a seatbelt on when being driven. She is the middle child and states the family is very closely knit and she has a strong social support system around her.

Fam Hx: She has a strong family history of allergies from her father’s side. Both of her two siblings also have allergies. There is no history of any chronic illnesses in the family. Both sets of grandparents on both sides are still alive and healthy. No first-degree relative has died of any suspected disease causes.

Surgical Hx: She denies any past surgical history.

Mental Hx: There is no history of mental illness such as depression or anxiety. There is also no history of self-harm tendencies or suicidality as well as homicidal ideation. However, she has a history of attention-deficit/ hyperactivity disorder (ADHD) since her childhood. She has been treated for this by psychotherapy but not medications as the symptoms were mild.

Violence Hx: She presents no violence history whatsoever. There are therefore no concerns or issues about her personal, home, community, sexual safety.

Reproductive Hx: She got her menarche at the age of 12 years. She states that she is not yet sexually active and is therefore consequently not pregnant. She is not on any contraceptive method as at now. Her last menstrual period (LMP) was on 05/12/2024.

ROS:

GENERAL: She denies fever, chills, and weight loss; but admits to malaise.

HEENT: She is positive for headaches. She also admits to photophobia, tearing, and itching of the eyes. Also admits to rhinorrhea, epistaxis, otorrhea, tinnitus, sore throat, and dysphagia.

SKIN: Denies itching, rashes, or eczema.

CARDIOVASCULAR: Negative for palpitations, chest pain or tightness, and peripheral edema.

RESPIRATORY: Positive for occasional wheezing, coughing productively, and shortness of breath.

GASTROINTESTINAL: Denies N/V/D as well as any changes in the bowel habits. She is negative for melena or frank blood in stool.

GENITOURINARY: She denies dysuria, a burning sensation on urination, or any abnormal urethral discharge. She is negative for pregnancy. Her LMP was 05/12/2024.

NEUROLOGICAL: She is negative for ataxia, paraesthesia, dizziness, syncope, or a loss in bowel and bladder control.

MUSCULOSKELETAL: Denies muscle, back, or joint pains.

HEMATOLOGIC: Negative for bleeding or chronic blood disorders.

LYMPHATICS: Negative for lymphadenopathy or splenectomy.

PSYCHIATRIC: Denies anxiety, depression, and other mental illness symptoms.

ENDOCRINOLOGIC: Negative for polyuria, polyphagia, and polydipsia. Also denies heat and cold intolerance. She denies ever having been on hormonal therapy.

REPRODUCTIVE: She denies any illness of the reproductive system. Her menses are regular and light. She is not sexually active and has no children (Para 0, G0).

ALLERGIES: She admits to being allergic but denies asthma, eczema, or hay fever amongst others.

O.

Physical exam:

Vital signs: T 97.2; BP 125/85; HR 72; RR 16; SpO₂ 96%; Wt. 191 lbs 5 oz.

HEENT: Afebrile but appears acutely ill. Ears: tympanic membranes normal bilaterally. Nose: nares erythematous, congested. There’s sinus tenderness to percussion. Pharynx: clear.

Neck: Supple, no lymphadenopathy.

Cardiovascular: S1 and S2 audible with no murmurs or bruits.

Respiratory: Lungs: clear, no rales, rhonchi, or crepitations. Wheezes ++

Diagnostic results: Covid-19 test negative, CBC shows leucocytosis, CRP elevated, and Hb 14.3 g/dL. She is to repeat labs ASO, CBC, CMP, lupus and adenovirus labs.

A.

Differential Diagnoses

1. Allergic Sinusitis: This condition causes nasal congestion manifesting as a runny nose and sneezing, postnasal drip, and itching of the throat, eyes, and nose (Jameson et al., 2022).
2. Conjunctivitis: It is inflammation of the conjunctiva that causes the eyes to turn pink. This inflammation could be due to a number of causes that include infection and allergic reactions (Jameson et al., 2022).

• Allergic rhinitis: This condition may happen seasonally or all the year round. It is characterized by itchy and watery eyes, sneezing, and sometimes coughing (Jameson et al., 2022). A superimposed bacterial infection may then cause the cough to become productive.

• Pharmacotherapy (Rosenthal & Burchum, 2020):

1. Hydroxyzine HCl 25 mg oral tablet; Take 1 tablet orally nightly; Qty: 30; Refills: 0
2. Olopatadine HCl 0.2 % Ophthalmic Solution; Instill 1 drop ophthalmically daily; Qty: 1; Refills: 0

• Ventolin 2 puffs q 4-6 hours PRN. Qty: 1 inhaler; Refills: 1

1. Cetirizine (Zyrtec) 10 mg orally O.D. Qty: 30; Refills: 30
2. Acetaminophen or APAP (Paracetamol) 1 g orally PRN. Qty: 30; Refills: 0

• Others:

1. Rest.
2. Take enough fluids.

• Shower every day before retiring to bed.

1. Vacuum all dust in the house.
2. Close all windows when appropriate.
3. Referral to a PMHNP for ADHD management.

• Follow up after four weeks.

Reflection

All ethical principles were followed during the evaluation. Health education was given on importance of adherence to medications and reporting side effects. The education was tailored to her age and social determinants of health such as educational achievement and access to quality healthcare services. She was given a follow up date.

 

 

 

References

Jameson, J.L., Fauci, A.S., Kasper, D.L., Hauser, S.L., Longo, D.L., & Loscalzo, J. (Eds) (2022). Harrison’s principles of internal medicine, 21^st ed. McGraw-Hill Education.

Papi, A., Blasi, F., Canonica, G. W., Morandi, L., Richeldi, L., & Rossi, A. (2020). Treatment strategies for asthma: Reshaping the concept of asthma management. Allergy, Asthma & Clinical Immunology, 16(1), 1-11. https://doi.org/10.1186/s13223-020-00472-8 

Ramsahai, J.M., Hansbro, P.M., & Wark, P.A.B. (2019). Mechanisms and management of asthma exacerbations. American Journal of Respiratory and Critical Care Medicine, 199(4), 423-432. https://doi.org/10.1164/rccm.201810-1931CI

Rosenthal, L.D., & Burchum, J.R. (2020). Lehne’s pharmacotherapeutics for advanced practice providers, 2^nd ed. Elsevier.