Sunday, June 30, 2013

I Need Help, My Allergies are Back!


I walked out to go call my next patient back into an exam room and when he responded I was pretty sure of what was going on.  For you see, this patient’s facial appearance of ‘raccoon eyes’ gave it all away. 
“Why don’t you come back into the exam room and tell me what’s happened.”
“Okay,” he replied, with a very definite nasal twang to it. 
“How long has your nose been plugged up like it is now?”
Answering in his nasal twang voice, “For about a week.  It has just gotten worse with all of the cottonwood trees blooming and the ragweed out.  I took my Zyrtec, but it hasn’t done anything this time.  I can hardly breathe and I cough all night.  My sinus’ are just stuffed full of crap.”
“What about your ears, do they feel full?”
“Yeah, oh and my throat is sore.”  As he sat there his nose started to drip and he needed to use some Kleenex.
“Okay, what’s typically draining from your nose, what color in other words?”
“I think it’s a dark yellow to sometimes green.”
“Any fevers, or wheezing?”
“No.”
“Have you had any past surgeries or have any other medical problems?”
“No.”
“So, besides your problems with your sinus allergies, nothing else is going on?”
“Nope.”
“How long have you had problems with allergies?”
“I started having problems with all of this stuff that blooms in the spring about five years ago.  Since then it has just gotten worse every year.  Now I have problems with allergies from spring until late fall.  The only time I get any relief is when it’s cold outside,” he twanged, as he reached for another Kleenex.
“Alright, well let me take a quick look at you and then you can tell me what you want to try for your allergies.”
The patient’s ears showed a dark gray tymphanic membrane (which meant his ears were full of sinus congestion), his nasal membranes were bright red, swollen, he had peri-orbital swelling going on (‘raccoon eyes’, swelling around his eyes due to his swollen, congested sinus’), as well as his throat was pink and swollen.  The rest of his exam was normal.
“Ok, Drew, you go by Drew correct?  Not Andy or Andrew?”
“I go by Drew.”
“Ok, Drew, why don’t you tell me what you have tried for your sinus congestion, what has worked and what hasn’t.”
“I’ve tried Claritin, Allergra and Zyrtec, all of which I get over the counter.  Zyrtec worked the best for me until this year and now it doesn’t even work anymore.  My primary care physician gave me some nasal steroid spray which helped until two years ago and then it quit.  I took some Afrin yesterday, but it’s not helping.  Gad, I need these sinus’ open again, I almost can’t breathe because they’re so clogged up.”
“Have you tried nasal saline washes?”
“No, what are those?”
“Well, ENT physicians, ear, nose andthroat doctors love saline nasal washes for their patients who have sinus congestion.  You use a small blue rubber bulb with 1 cup of saline water.  You gently squirt ½ cup of the saline mixture up each nostril three times a day.  This gently washes out your sinus’ and keeps all of the allergens washed out so that you don’t have problems with all of the ragweed, cottonwood flowering, etc.  Do you want to try it?”
“I’ll try anything at this stage.”
“Okay, well let me give you the instructions for it and then you can go pick up the supplies for it at the drugstore or grocery store.  Because your allergies have gotten so bad so quickly, I also want to send you to an allergist.  I think it’s probably time for you to get started on allergy shots.  Is that okay?”
“Yeah, that sounds really good.”
“Okay, hang tight, let me go make a call for you to see how soon she can get you into be seen.  I’ll be right back.”
I left the exam room and went to go call Dr. Miller’s office.  After I explained to the receptionist that I had a patient who needed to be seen in the near future instead of weeks away, her receptionist advised me that Dr. Miller had a patient cancellation for 3 pm that afternoon and could my patient be there then?
I advised her that Drew would be there and after giving her the details of his insurance plan, I hung up the phone to go tell Drew his good luck.
I walked back into the exam room and told Drew of his appointment time after which his facial appearance changed into a smile and in his nasal twang voice replied, “Thanks.”
After Drew left the clinic, I didn’t expect to see him again.  But two weeks later he walked back into the clinic and asked to speak to me.   I walked out to the patient waiting room after the receptionist called and told me who was there waiting.
“Hi, Drew, what can I do for you?”
“Look, my face, I’m not swollen.  I can also talk like normal, I don’t have a frog in my voice anymore.”
“I’m impressed.  What all did Dr. Miller do for you?”
“Oh, she started off by telling me I was one of the worst cases of seasonal allergies she has seen in a while.  I spent the next two hours in her office getting all sorts of allergy testing done, she did who knows how many allergy tests on my backside.  Boy did I itch that night.  She also started me on allergy shots last week. She then told me to use Zyrtec-D, the stuff that she says has Sudafed in it, along with a different kind of nasal steroid spray and the saline washes you put me on.  What a difference it’s made.  At any rate, I just wanted to say thanks for sending me over to her, now I can go outside and not immediately close up from all the pollen in the air."
“Well, you’re quite welcome, Drew, I’m glad she helped you out.”
“So, am I.  Having those ‘raccoon eyes’ wasn’t fun.  Now no one at work is asking me what’s wrong.”

Signs/Symptoms of Allergic Rhinitis

Sneezing
Sinus congestion
Runny nose
Seasonal exposure to either indoor or outdoor allergens (pollen, ragweed, etc)
Pet exposure

Treatment

Saline nasal washes
Anti-histamines (Zyrtec, Claritin, Allegra) and/or with decongestant (Sudafed)
Intranasal steroid sprays (either prescription or over the counter
Oral leukotriene inhibitors (Xyzal or Singulair)
Allergy shots (for those patients with severe symptoms, patients state that these work after 1 year of injections and the effect can last up to 3 years after the last shot).

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