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INTRODUCTION

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CASE LEARNING OBJECTIVES

  • List the typical symptoms of allergic rhinitis (AR) and identify the most troublesome one

  • List the reasons for referral to an allergy specialist

  • Discuss the categories of pharmacotherapy choices for treatment of AR

  • Rank the pharmacotherapy choices for efficacy in treating nasal congestion

  • Describe an approach for treatment of mild AR with OTC drugs

  • Create a therapy plan for treatment of moderate-to-severe AR

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PATIENT PRESENTATION

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Chief Complaint

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"What can you recommend for my itchy, stuffy nose and sneezing?"

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History of Present Illness

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Brenda Baresdale is a 27-year-old female who comes into your retail pharmacy seeking advice for the above complaints. Your history reveals the following information. She began having significant nasal allergy symptoms for the first time about 8 years ago after moving to the Southwest (Phoenix, AZ) from the Midwest (Zionsville, IN). Her nose is affected most, but there are some mouth, throat, chest, and even occasional eye symptoms. The congestion in the nasal passages is so bad that usually she can breathe only through her mouth. The nasal symptoms are characterized by watery discharge, sneezing, itch, and severe congestion. Sometimes she has "itchiness" in the roof of the mouth and back of the throat. Sometimes there is cough, which seems to be stimulated by nasal discharge "dripping down" the back of the throat. The cough is usually mild and nonproductive. When her other symptoms are at their worst, there is sometimes a sensation of "chest tightness." Also, sometimes both her eyes become itchy, red, and even have increased tearing. She cannot identify specific triggers for her symptoms other than seasons of the year. Her condition is the worst from about May through July. However, in most years, she also has problems during the period from mid-September through December. Actually, in the last few years, she even noticed symptoms at other times, although less frequently and less severely. When her symptoms start in May and mid-September, they occur only two to three times per week. However, after 2–3 weeks, they increase in frequency to almost every day. She has horses, and cares for them every weekend, but her symptoms do not seem to be worse at those times. Sometimes her symptoms are worse when she spends a lot of time outdoors. However, she also notices that being in her kitchen can sometimes start her sneezing. She has tried several medications, some of which have helped. She began treating herself 4–5 years ago, with loratadine (Claritin), but that hardly helped at all. Next, she tried diphenhydramine, which did help, and she has continued that medication. The first few days she takes it, she notices sleepiness, but that "wears off" if she continues it for several days. She has tried decongestant nose sprays, usually oxymetazoline, in the past, especially when the stuffy nose was bad. It did help for a while. She ...

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