Medical Case

Case Study

Allergist Consultation Report

Patient Name: Darryl McFadden Date: 5-4-04

Ref. Physician: Steve Glass, M.D.

Darryl McFadden’s history is such that he complains of nasal blockage (blockage of nasal passages due to membranes with swollen blood vessels), postnasal drip (too much mucus is produced in the nasal cavity), and cough especially at night. His symptoms are perennial (lasting for long period of times usually through the year), but mainly from March through October. He says he has been getting allergy injections sporadically over the past five years, but is not doing well.

His history sheet reveals that he is exposed to a cat and also to dust and other factors in his household, and that seems to make him worse. He has been on Entex medication, the only treatment he has had other than his injections.

The physical examination revealed the lungs were clear. There were no rales (abnormal lung sounds that can be detected by medical instruments). There were decreased breath sounds on expiration (passive process of breathing out). There was some nasal congestion around the turbinates (long and curved bone that sticks out of breathing passage). There were no obvious pus pockets. There was a premaxillary edema bilaterally (upper jaw swelling on both sides), especially on the right. There was some mild postnasal drip and there was some mild cervical lymphadenopathy (enlarged and swollen lymph nodes disease in the neck). There was some slight tenderness in the epigastric region (abdomen upper central region) but no evidence of any masses or liver or spleen enlargement.

Skin scratch testing was performed, revealing a definite allergy (hypersensitivity reactionof the immune system) to trees, grasses, weeds, ragweed, mold, and also to feathers, house dust and mite dust, and dogs and cats.

The patient also had a pulmonary function (test to measure lung intake and outtake of air) that was unremarkable. Sinus x-rays failed to show any sinus disease....