The patient presents today with the complaint of nasal (1)__________ and postnasal drip, with watery eyes. The patient is 30 years old and has a history of allergies in the past. She reports having had allergy therapy as a child, with some relief of her symptoms. She moved to this area approximately 5 years ago and did well for the first 2 years and then started developing these symptoms over the past 3 years. When she works outside or mows the lawn she reports that her eyes water and that she sneezes almost uncontrollably. She reports that she can predict the (2)_________ count based on the severity of her own symptoms. She has used over-the-counter allergy preparations but has not sought any medical attention for her allergies in years. She denies any (3)__________ nasal discharge. She has not had any prior nasal or sinus surgery.
On examination, the patient is noted to have evidence of (4)__________, and she appears congested. The ears are within normal limits. The nose reveals severe edema of the (5)__________, with a pale bluish discoloration. There is clear drainage within the nose. There is a mild right nasal septal (6)__________, with no purulence in the nose. The mucosa decongests well with Neo-Synephrine spray. There are no polyps visualized in the nose, and nasal (7)__________ reveals no masses or purulence, with particular attention to the middle meatuses bilaterally. The nasopharynx, (8)__________, and larynx were also visualized with the endoscope and were noted to be within normal limits. The (9)__________ and oral cavity are without masses or (10)__________. The neck is without nodes.
In summary, she has evidence of severe allergic (11)__________. She was treated with Claritin-D 24-hour medication, and she is to take 1 tablet by mouth every day as needed for congestion. She was also given a sample of Nasacort AQ nasal spray, and she is to use 2 puffs, each nostril, daily for 3 weeks. I have advised her to avoid activities which expose her to (12)__________, which she knows exacerbate her symptoms. For example, she is to avoid mowing the lawn and working in her garden if possible. I have advised her to follow up with an allergist for repeat allergy testing. I have given her the names and numbers of 3 allergists in her area so that she may follow up there. She does not need to follow up in my office, unless there is a change in her symptoms.
Question 2
The patient is a 5-year-old boy who presents with a 2-day history of fever and severe right ear pain. The mother reports that the child has a history of frequent (1)___________ ear infections. He recently had an upper respiratory (2)__________ infection and over the past 2 days has developed fever and pain in his right ear. There is no drainage from the ear. The mother reports that the child has had a similar episode in the past, with development of ear drainage, which required treatment with antibiotics.
On examination, the child is not at all ill appearing. The examination of the left ear reveals that the external (3)__________ canal is clear, and the (4)__________ is retracted, with a small air-fluid level. Examination of the right ear reveals the external auditory canal to be clear. The right tympanic membrane is (5)__________ and bulging. (6)__________ cannot be visualized on the right tympanic membrane. The nose is without masses or purulence. The oropharynx and oral cavity are without erythema, masses, or (7)__________. The neck reveals multiple small, nontender nodes.
Audiogram reveals bilateral mild conductive hearing loss, with a flat (8)__________ on the right and a negative middle ear pressure on tympanometric testing of the left ear.
In summary, the patient has a right acute otitis media and an early left (9)__________ otitis media. He has been treated with Augmentin 200 mg/tsp 1 tsp p.o. b.i.d. and is to use Childrens Tylenol as needed for fever. He is to follow up in this office in 3 weeks. The mother is to call immediately if he develops any high fever, ear drainage, severe pain, or develops any (10)__________, or appears very ill.
Portrait of a Shy Albatross. Note the large, hooked beak and nasal tubes.
Middle nasal conchae
Specula: (A) Vienna nasal speculum; (B) Ives-Fanster rectal speculum.
A pacemaker in a patient’s chest.
Grief Responses and Patient Verbalization
Variations in patient response to drugs