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Abstract: The patient is a 17-year-old boy who reported that he received a bouquet of flowers 3 days ago at the end of the college entrance examinations and had symptoms of nasal congestion and runny nose since then, thinking that it was a cold. After systematic examination, he was diagnosed with allergic rhinitis and was treated with cetirizine hydrochloride tablets and loratadine tablets, and his condition was controlled.
Basic information】Male, 17 years old
Type of disease】Allergic rhinitis
Hospital】The First Affiliated Hospital of Xi’an Jiaotong University
Date of consultation】June 2022
Treatment plan】Oral medication (cetirizine hydrochloride tablets, loratadine tablets)
Treatment Period】Inpatient treatment for 3 days, outpatient review after 2 weeks
Effectiveness of treatment】The symptoms of nasal congestion and runny nose disappeared and the condition was stable
I. First interview
The boy complained that he received a bouquet of flowers from his family 3 days ago when he stepped out of the college entrance examination hall, after which he had symptoms of nasal congestion and runny nose, but his sense of smell was normal, not accompanied by dizziness, headache, nausea, panic and palpitations. During nasal endoscopy, the patient was found to have bilateral mucous membranes in the nasal cavity with congestion and edema, a small amount of purulent secretions in the middle nasal passages bilaterally, and hypertrophy of the inferior turbinates bilaterally with mulberry-like changes on the surface. The serum specific IgE test was positive for the presence of specific antibodies to pollen. The initial diagnosis was allergic rhinitis and the patient was admitted to the hospital.
II. Treatment history
I informed the patient of the diagnosis and explained that it was allergic rhinitis caused by exposure to pollen and that anti-allergic drugs should be applied immediately to prevent the disease from progressing or getting worse. The patient and his family indicated that they were willing to accept the treatment and would actively cooperate with it. I prescribed cetirizine hydrochloride tablets and loratadine tablets, which are selective histamine H1 receptor receptor antagonists, to effectively reduce his symptoms of nasal congestion and runny nose. On the first day of medication, the patient showed slight weakness, dry mouth and drowsiness, which I considered as adverse drug reactions and did not do any special treatment for the time being because the symptoms were mild, and the symptoms subsided with the second day.
III. Treatment effect
The patient showed nasal congestion and runny nose before treatment. After 3 days of the above drug treatment, the patient complained that the symptoms of nasal congestion and runny nose disappeared, and his sleep, diet and urine and stool were normal, with no other obvious discomfort symptoms. When the nasal endoscopy was repeated, no abnormalities such as nasal mucous membrane edema and congestion were seen, and the patient was in good mental condition and clear.
IV. Notes
I was very happy to see that the boy’s condition was under control and his symptoms disappeared. When he was discharged from the hospital, I repeatedly advised him and his mother that since he was allergic to pollen and allergic rhinitis was prone to recurrence, they should avoid contact with pollen, dust, car exhaust and other factors that could lead to recurrence of the disease, and wear a mask when going out. Pay attention to the ventilation of the living environment, keep the air circulating, and maintain the appropriate temperature and humidity. Eat a light diet and avoid spicy and irritating foods as much as possible. In addition, if you find that there is a tendency of relapse after discharge from the hospital, you should seek medical treatment immediately.
V. Personal insight
Patients with allergic rhinitis usually suffer from nasal congestion and runny nose, which are somewhat similar to the adverse symptoms caused by colds and cold, and it is easy to misdiagnose and use medication indiscriminately. In addition, allergic rhinitis usually cannot be cured, and if you come into contact with allergens again, you are more likely to have a relapse, so you should do your best to protect yourself.