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James is a 24-year-old male financial advisor who seeks relief...

James is a 24-year-old male financial advisor who seeks relief...

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Author: brecht 2017
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James is a 24-year-old male financial advisor who seeks relief from itchy eyes, repetitive sneezing, and nasal congestion that worsens at night

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James is a 24-year-old male financial advisor who seeks relief from itchy eyes, repetitive sneezing, and nasal congestion that worsens at night.  He says “If I could only sleep at night, I could handle this.”
Discussion questions part one: 
What are the most likely diagnoses?
What should you focus on during your examination?
Discussion Part Two (graded)
ADDITIONAL HISTORY:
The history revealed that these symptoms occur every spring/summer and last for 6 to 8 weeks.  As a teenager, he worked in his father’s hay fields.  His mother had asthma as a child.  The physical examination showed that his internal nares were swollen and moist and there was a clear discharge without purulence.  There was no wheezing and the lungs were clear to auscultation and percussion.
Discussion questions part two:What is your diagnosis now?
How would you begin treatments?
Discussion Part Three (graded)
James now tells you that he is tired of taking drugs and fears they may stop working like they have in the past.  He says he has tried 2-3 nose sprays in the past as well as loratidine, cetirizine and fexotenadine.
Discussion questions part three:What other treatment options are there?
What else might you do with James?


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