(Disclaimer: This article is for scientific use only. To protect patient privacy, the relevant information in the following content has been processed)
Abstract: Mr. Mao developed nasal congestion, bilateral nasal hypoventilation, runny nose, sometimes accompanied by sneezing and mild headache 1 month ago with no obvious cause. Nasal endoscopy revealed chronic congestion and edema of the nasal mucosa, bilateral inferior turbinate hypertrophy, which showed mulberry-like changes, and a preliminary diagnosis of allergic rhinitis. Mr. Mao was given medication, including budesonide nasal spray and cetirizine hydrochloride tablets. The symptoms improved after 7 days of drug treatment and the condition was stable.
Basic information】Male, 60 years old
Disease Type】Allergic rhinitis
Hospital】The First Affiliated Hospital of Xi’an Jiaotong University
Date of Consultation】June 2022
Treatment plan】Medication (budesonide nasal spray, cetirizine hydrochloride tablets)
Treatment Period】Inpatient treatment for 3 days, outpatient review after 2 weeks
【Treatment effect】The symptoms of nasal congestion improved after medication, and the condition of allergic rhinitis was stable
I. Initial consultation
Mr. Mao reported that a month ago, he developed nasal congestion, bilateral nasal ventilation, runny nose, sometimes sneezing, mild headache, and no other symptoms. After the onset of discomfort, he took anti-inflammatory drugs at home for treatment, but the specific medication was not known, and the effect was very little, and the symptoms of nasal congestion gradually increased, so he came to the hospital for treatment. Mr. Mao reported that he had a history of hypertension for more than 10 years, denied a history of coronary heart disease, diabetes, etc., and denied a history of drug allergy.
II. Treatment process
Mr. Mao was hospitalized and underwent professional examination. Nasal endoscopy revealed chronic congestion and edema of the nasal mucosa, bilateral inferior turbinate hypertrophy showing mulberry-like changes, and positive allergen nasal excitation test, therefore, Mr. Mao was diagnosed with allergic rhinitis. After explaining his condition to Mr. Mao, he agreed to the pharmacological anti-allergic treatment, so he was treated with topical budesonide nasal spray for nasal spray and combined with oral treatment with cetirizine hydrochloride tablets. After that, I also reminded the patient to pay attention to suspected allergens in daily life, such as dust and seafood.
III. Treatment effect
After 3 days of hospitalization, Mr. Mao’s symptoms of nasal congestion and runny nose improved compared with before, and there were no symptoms of headache and no abnormalities in other examinations, so he could be discharged home for medication after comprehensive consideration. After taking medication at home for 2 weeks, Mr. Mao reported that his nasal congestion had significantly improved and he did not have runny nose, sneezing and headache. The nasal endoscopy revealed that the congestion and edema of the nasal mucosa had improved significantly compared with the previous situation.
IV. Precautions
After seeing the improvement of Mr. Mao’s nasal congestion, I felt happy for Mr. Mao. However, since allergic rhinitis is prone to recurrence, i.e., after being exposed to allergens again, it can cause discomfort again, so I suggested Mr. Mao to clarify the allergens as much as possible and avoid suspected allergens as much as possible in daily life, common allergens include dust, mites, pollen and so on. At home, we should keep indoor air, clothes and bed quilts regularly exposed to the sun to help reduce mites. Try to eat a light diet, avoid seafood and other allergenic foods, and go to the hospital promptly after discomfort, and avoid taking drugs on your own to avoid delays.
V. Personal Insights
Allergic rhinitis, also known as hay fever or kwashiorkor fever, has obvious seasonal and regional characteristics, and the symptoms are similar to those of colds, so it is easy to be confused. Mr. Mao in this case was previously thought to be a common cold caused by nasal inflammation, self-medication treatment, the effect is not good before coming to the hospital, in fact, if in the first symptoms, timely medical treatment to effectively improve the symptoms, will be able to improve the quality of life in a timely manner, not to appear more serious discomfort such as headaches.