Allergic Rhinitis in Children

Alex, a 7 year-old Caucasian male, is brought to the primary care clinic by his mother for a routine well-child check. In obtaining the history the Nurse Practitioner (NP) is made aware of increasing issues with snoring, nasal congestion, ophthalmic itching, frequent sore throat upon wakening, and afternoon fatigue. Home treatment includes over the counter (OTC) cetirizine (Zyrtec) 10mg daily for the last month with minimal improvement, mother reports the medication increases afternoon fatigue and difficulty concentrating at school. Alex has no previous significant medical history, is up-to-date on immunizations, and has no other complaints. Alex's father had significant asthma and atopic dermatitis as a child. Physical exam reveals a normally developing Tanner 1 school-aged male, who is appropriate in cognition and use of fine and gross motor skills. Tympanic membranes are clear. Palpebral conjunctiva mildly injected bilaterally. The ophthalmic exam is otherwise unremarkable. Nares are patent, but inferior and medial turbinate's are pale and mildly edematous with scant to moderate clear rhinorrhea. Pharynx with mild cobble stoning and noted clear posterior drainage. Tonsils+2/4 without erythema or drainage. Neck is supple without lymphadenopathy. Heart rate is 88 beats-per-minute. S1, S2 noted and regular without murmur. Lungs clear to auscultation throughout, respirations even and unlabored. The remainder of the physical exam is unremarkable.