Otorhinolaryngology (ENT) Case

Here’s a case assigned to me during my Otorhinolaryngology (ENT) rotation. Can you guys help me out in answering the questions?

CASE: A 25 year old male factory worker was seen at the out-patient department because of nasal congestion.

History of Present Illness: History started 1 year prior to consult when the patient started to experience occasional difficulty in breathing on both nostrils often accompanied with sneezing and morning sniffles. He would also complain of watery and itchy eyes .Nasal discharge is often clear and watery. He works in a garment factory in Bulacan.

Review of systems:

  • Occasional anosmia
  • Occasional nasal pain and headache

 

Past Medical History: He had asthma until age 12; Denies any food or drug allergies

Family history:
– Hypertension – father
–  Psoriasis – brother
Physical examination:

 Otoscopy: Unremarkable

 Anterior rhinoscopy: pale and boggy turbinates, with clear discharge from both nostrils

Oral Cavity: (+) postnasal drip cobblestoning

Here are the questions:

  1. What is your initial impression?
  2. What are your differentials?
  3. What other pertinent information do you wish to gather from your patient’s history and why?
  4. What diagnostic tests can you request to help you in your diagnosis?
  5. What are your expected results in the tests?
  6. What can you recommend to your patient to alleviate his symptoms?
  7. How would you manage our patient?
  8. What is the ARIA classification?
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