General

Data
Patient Profile...

JP
RPVD
10/F
Born on July 31, 2004
Filipino
Roman Catholic
Quezon City
Old patient from OPDVMMC
Informant: Patient
Reliability: 90%

Chief
Reasoncomplaint
for Admission
Parang
barado ang
ilong
Nasal
Congestion

A CASE
OF ASTHMATIC 10- YEAR- OLD
FEMALE WITH NASAL CONGESTION

CASE
GRAND
PRESENTATION
ROUNDS

History
of Present
Present state
of health
3illness
days PTC
4 days PTA

No medication, no consult was

done

Present stateof
of health
History
Present
illness
2 days PTC

No medication , no consult was

done

Present state
of health
History
Present
1 day PTA
illness

Past
Medical
History
Past
health
records

Past
Medical
History
Past health
records

HEADSS
Past health records

HEADSS
Past health records

Family
History
PAST MEDICAL
HISTORY:
(+)Hypertensio
n
Grand Mother
(-) Asthma
(-) Diabetes
(-) Heart
Disease

(+)Asthma
Auntie
(-)Hypertension
(-) Diabetes
(-) Heart Disease

Review
of Systems
System
Appraisal
General: (-) easy fatigability, (-) weight loss
Skin: (-)rashes, (-)redness, (-)sores, (-) pruritus or dryness.
(-)alopecia, (-)changes in nails, or size and color of moles
HEENT: (-) headache, (-)head injury, (-) dizziness, (-) blurring of vision,
Eyes: (-) eye pain, or flashing lights (-) excessive tearing or diplopia,
Ears:(-)tinnitus, (-)hearing loss, (-)earaches, or vertigo, (-)otalgia, or
otorrhea. Nose: (-) epistaxis, (-) postnasal drip, Throat: (-)dryness of
mouth and throat.(-)bleeding gums, (-)sore tongue, or hoarseness
Cardiorespiratory: (-) cough, (-)hemoptysis (-)dyspnea (-)chestpain,
(-)palpitations
Gastrointerstinal: Good appetite (-)heartburn (-) dysphagia,
(-)diarrhea, (-)excessive belching or excessive flatulence

Review
of Systems
System
Appraisal
Gastrointestinal: Good appetite, (-)heartburn, (-) dysphagia, (-)diarrhea,
(-)excessive belching or excessive flatulence
Cardiorespiratory: (-)cough,(-)hemoptysis (-)dyspnea (-)chestpain,
(-)palpitations
Gastrointestinal: Good appetite (-)heartburn (-) dysphagia, (-)diarrhea,
(-)excessive belching or excessive flatulence
Urinary: (-)polyuria, (-) dysuria, (-)flank pain (-)urinary urgency and
incontinence
(-)dribbling of urine
Endocrine: (-)polyphagia and polydipsia
(-) heat or cold intolerance, (-)excessive sweating.

General Survey
Patient is conscious, coherent, spontaneous speech
not in cardiorespiratory distress.
Weight: 37.72kg Height: 138cm BMI:19.78 kg/m
(normal)
Vital signs:
BP: 90/60

PR: 86

RR:17

T: 36.2

Skin: warm, moist, good skin turgor

HEENT:
Head:Symmetrical, with smooth contours, Scalp is
intact, without scales , plaques, or other lesions.
Eyes:Eyebrows grossly symmetrical with well distributed
hair. Eyelids are smooth, symmetrical without ptosis or
lesions. Ears:Auricles symmetrical with no lesions or
deformities. (+)brownish material partially occluded in
the external canal of both ears; no discharge seen.
Tympanic membranes intact, smooth, and non-hyperemic.
Nose:Symmetrical, with nasal septum in the midline. (+)
nasal mucosa moist, pale, grayish pink in color. No
ulcer or polyps. No sinus tenderness.Throat/Mouth:no
tonsillopharyngeal congestion

Neck:
Symmetric,
supple,
without
cervical
lymphadenopathies, pulsations or lesions. Trachea in the
midline. Thyroid gland is not englarged
Chest/Lungs: symmetric expansion, no retractions, no
lesions, Equal tactile fremitus on both lung fields. No
costochondral and intercostal tenderness, Clear breath
sounds.
Cardiovascular: adynamic
pulsations, no murmurs

precordium,

no

visible

Abdomen: flat, symmetrical, no lesions, normoactive

bowel sounds, Soft, without masses or tenderness upon
superficial palpation. Tympanitic percussion note on all
abdominal quadrants.
Musculoskeletal:Extremities symmetric, full & equal
pulses,without discoloration and swelling, full range of
motion

Cranial Nerves:

Awake, alert, conscious, coherent, oriented to time, place and

person,
Cranial Nerves
CN I able to smell
CN II,III able to see, pupils 2-3mm equally reactive to light
CN III, IV and VI EOMs intact
CN V corneal reflex intact, facial sensation intact, able to clench
teeth
CN VII Symmetrical nasolabial fold, able to wrinkle forehead, close
eyelids tightly, smile, puff cheeks, and pout lips symmetrically
CN VIII- Able to hear on both ears
CN IX & X- uvula at midline and able to swallow, (+) gag reflex
CN XI Able to shrug both shoulders and turn head to both sides
CN XII- Able to protrude tongue in the midline

SALIENT FEATURES
Nasal
Congesti
on

10
y/o

Nasal
itchine
ss

Asthm
a

Rhinorr
hea
Sneezi
ng

Differential
Diagnosis

Papillary
Necrosis
Asthma

Papillary
Necrosis
AURI

Papillary Necrosis
Foreign
body

Rhinitis
AcuteAllergic
Cystitis/Pyelonephritis

Final Diagnosis

Plan/Managemen
t
Non-Pharmacologic
Management

Avoidance of indoor molds exposure at home

Avoidance of animal dander exposure at home
Basis:
Increase oral fluid intake
Pharmacologic Management

Cetirizine 10mg/tab, Take 1 tab once a day at bedtime for 5 days

Phenylephrine hydrochloride, chlorphenamine maleate,(Disudrin)
60ml/bottle, Take 5 ml every 6 hours as needed for nasal
congestion

Discussion

Allergic Rhinitis
MORTEL, Sienna Ann A.
Veterans Memorial Medical Center

 10/F
Nasal
congestion
Nasal itchiness
Sneezing
Rhinorrhea
(+) Asthma
(+) Allergy
(+) Family
History of

Allergic Rhinitis
Inflammatory disorder of
mucosa characterized by

the

nasal

nasal congestion
rhinorrhea
itching
sneezing
conjunctival irritation

It is a major chronic disease of children

based on its high prevalence, co
morbidities, and detrimental effects on
the quality of life and school performance.
Nelson Textbook of Pediatrics 18th edition

Etiology
Airborne pollens
Indoor allergens

Nelson Textbook of Pediatrics 18th edition

Epidemiology
Prevalence peaks late in childhood
Symptoms may appear during
infancy with the diagnosis generally
established by 6 year of age1
The overall prevalence of allergic
rhinitis in the Philippines based on
the 2008 National Nutrition and
Health Survey is 20.0%2
Nelson Textbook of Pediatrics 18th edition

The Official Journal of Asia Pacific Allergy 2008

Risk Factors
Family history of atopy
IgE >100 IU/ml
Children introduced to foods or
formula early in infancy
Heavy exposure to indoor allergen

Nelson Textbook of Pediatrics 18th edition

The nasal allergic

response

allergen
IgE

preformed &
newly formed
mediators/cytokines

Endothelial
cell activation

mast cell

Leukocyte
infiltration and
activation
(lymphocytes, eosinophils,
basophils)

IMMEDIATE (early)
RESPONSE
Sneezing
Pruritus
Rhinorrhea
Nasal obstruction
Ocular symptoms

LATE-PHASE
RESPONSES

Nasal
obstruction
Rhinorrhea

Nasal
hyperresponsivene
ss
To allergens

To irritants and
to
atmospheric
changes
Nelson Textbook of Pediatrics 18th edition

Clinical Manifestation

Nasal itching
Allergic salute
Nasal crease
Intermittent nasal congestion
Sneezing
Clear rhinorrhea
Conjunctival irritation
Allergic gape
Allergic shiners
Wheezing and coughing

Differential Diagnosis
Rhinosinusitis with or without nasal polyps
Mechanical Factors
Deviated septum
Hypertrophic turbinates
Adenoidal hypertrophy
Anatomical variants in the ostiomeatal
complex
Foreign bodies
Choanal atresia

Diagnosis in Primary Care

Setting

ARIA Guidelines 2008

Allergic Rhinitis
Classification

ARIA Guidelines 2008

Laboratory Work up
Epicutaneous skin test
Serum immunoassay

Nelson Textbook of Pediatrics 18th edition

Immunoassay vs Skin Test

for Diagnosis of Allergy

Treatment Goals
Unimpaired sleep
Ability to undertake normal daily
activities, including work and school
attendance, without limitation or
impairment, and ability to participate
fully in sport and leisure
No troublesome symptoms
No or minimal side effects of rhinitis
treatment
ARIA Guidelines 2008

Epidemiological Evidence for

Combined Allergic Rhinitis and
Asthma
70-90% of patients with asthma also have
rhinitis
40-50% of patients with allergic rhinitis
also have asthma.

Combined Allergic Rhinitis and Asthma. World Allergy Organization 2011

Allergic Rhinitis and its

Impact on Asthma ARIA
(2010)

Guideline Objectives
To develop explicit, unambiguous,
and transparent clinical
recommendations systematically for
treatment of allergic rhinitis on the
basis of current best evidence

Intervention and Practices

Question

Allergic Rhinitis
Questionnaire

Yes

No

1. Do you have any of the following symptoms?

Symptoms on only one side of your nose
Thick, green or yellow discharge from nose
Postnasal drip with thick mucus and/or runny nose
Facial pain
Recurrent nose bleed
Lose of smell
2. Do you have any of the following symptoms for at
least one hour on most days
Watery runny nose
Sneezing, especially violent and in bouts
Nasal obstruction
Nasal itching
Conjunctivitis (red, itchy)

ARIA Guidelines 2008

Allergic Rhinitis Diagnosis

Guide Findings that Support
Diagnostic Tool
Diagnosis

Physical examination

Transverse crease of nose,

allergic shiners, allergic
salute

In Persistent rhinitis:
Anterior rhinoscopy using speculum and
mirror gives limited but often valuable
information
Nasal endoscopy may be needed to
exclude other causes of rhinitis, nasal
polyps, and anatomic abnormalities

Exclusion of other cause

Trial of therapy

Improvement with
antihistamines or
intranasal
glucocorticosteroid

Allergy skin testing or measurement of

allergen specific Ig E in serum (if
symptoms are persistent and/or

Confirms presence of
atopy
ARIA Guidelines 2008
Specific triggers

Treatment
Removal and avoidance of offending
allergen
Oral antihistamines

Oral Antihistamines

Newer Generation Oral

Antihistamines
First line treatment for mild allergic rhinitis
Effective for
Rhinorrhea
Nasal pruritus
Sneezing
Less effective for
Nasal blockage
Minimal or no sedative effects
Once daily administration
Rapid onset and 24 hour duration of action

Nasal Corticosteroids
Beclomethasone dipropionate
Budesonide
Ciclesonide
Flunisolide
Fluticasone propionate
Mometasone furoate
Triamcinolone acetonide

* Currently only approved for asthma

Nasal Corticosteroids
1

reduction of
mucosal inflammation

reduction of
mucosal mast cells

reduction of
reduction of
acute allergic reactions
late phase reactions
priming
nasal hyperresponsiveness

suppression of

glandular activity
and vascular leaka
induction of
vasoconstriction

reduction of
symptoms and exacerbations

ARIA Guidelines 2008

Agents and actions

Oral
antihistam
ines

Nasal
antihistam
ines

Cys-LT1
receptor
antagonists

Nasal
steroids

Nasal
decongest
ants

Oral
decongest
ants

Nasal
ipratropium

Nasal
cromones

Rhinorrhea

++

++

++

+++

+++

Congestion

+++

++++

++

Sneezing

++

++

++

+++

Pruritus

++

++

+++

Ocular symptoms

++

++

++

Onset of action

1 hr

15 min

48 hr

12 hr

5-15 min

1 hr

15-30
min

Duration

12-24 hr

6-12 hr

24 hr

12-48 hr

3-6 hr

12-24 hr

4-12 hr

2-6 hr

Modified from van Cauwenberge P Allergy 2000;55:116-134

Complications

Chronic sinusitis
Eustachian tube obstruction
Otitis media
Obstructive sleep apnea

Nelson Textbook of Pediatrics 18th edition

Prognosis
The reported rate of remission of AR
among children are10 -23%.
Therapy with 2nd generation anti
histamine and intranasal
corticosteroids significantly improves
health related quality life measures
in patients of all ages

Nelson Textbook of Pediatrics 18th edition

THANK YOU!