10 History
It’s normal not to breathe through your nose.
A patient said this to me recently, and I’ve heard variations of this from a few other patients. Actually, it’s quite normal to breathe through your nose, but I use this example to highlight the necessary peril you face when taking a patient’s history to make the clinical diagnosis of allergy or allergic rhinitis. The clinical history is vital to making the diagnosis, but it’s not uncommon for patients who have lived with certain symptoms for longer duration that those symptoms (such as nasal congestion or nasal obstruction) become their new “normal.”
Hence many patients consider seasonal allergy symptoms or “hay fever” to be normal, that everyone has them, and may not give you those symptoms without some prompting. They may complain that they have “symptoms” (or “the sinus” or “the crud”). Needless to say, it is necessary to dig further and record what exactly these symptoms are (not just to document for billing purposes) but to help in determining the most likely diagnosis and treatment for the patient.
10.1 History of Present Illness
What are the necessary parts of the history of present illness (HPI)? Type of symptoms, timing and duration, frequency, inciting exposures, current/past medications used to treat, comorbid conditions (asthma, eczema, etc.), family history of atopy (asthma, eczema, etc.), response to any medications used consist this information.
What kind of symptoms do I look for? ▶Table 10.1 lists general symptoms that are suggestive of allergic disease and other diseases. It is not exhaustive, encompassing, or absolute.
Symptoms suggestive of allergy | Symptoms suggestive of other disorders |
Clear nasal drainage a | Discolored nasal drainage |
Nasal congestion/obstruction a | Decreased sense of smell/taste |
Sneezing/sniffing a | Headache/facial or sinus pain |
Eye, nasal, oral, throat itching a | Oral or nasal masses/ulcers |
Red and/or water eyes | Discolored sputum |
Wheezing/coughing (dry) | |
aThese symptoms rank highest in diagnostic utility for allergic rhinitis. | |
Other symptoms that might suggest allergy include hyposmia/anosmia, snoring, decreased hearing/“clogged ears” due to middle ear fluid, snoring, sore throat, postnasal drip, hoarseness/throat clearing.
What about timing and symptoms? Are the symptoms year-round (perennial), seasonal, or intermittent (with exposure to an allergic trigger)?
Patients with year-round allergies tend to report congestive symptoms (sinus pressure, nasal blockage/congestion, and snoring). Patients with season allergies are more likely to complain of sore throat, cough, sneezing, rhinorrhea, and postnasal drip.
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