9 yrs old female w/c/o stuffy nose

February 16, 2023

NOTE: THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT.

PATIENT HISTORY: Pt is a 9 yrs old female

Till the age of 6-7 yrs, she c/o constipation (2 days no defecation), passing very hard stool. Dr prescribed high fibre diet taking which normalised her bowel movement.

At that time only, she also used to c/o digestive issues (acid reflux, sour burps, sour aftertaste, foul smell from mouth) on eating something fried, oily and spicy. Now the frequency has decreased a lot after starting high fibre diet and taking lot of water.

Since childhood, she used to suffer often from cough and cold (nasal congestion and dry cough), would last for 8-10 days, happening 2-3 times/yr, mostly during winter months or while in AC during summer.

At the age of 5-6 yrs, she c/o swallowing difficulty and throat pain, stuffy nose. Dr told that her tonsils are inflamed and she should avoid catching cold at any cost. To relief nasal blockage nasal drops were prescribed which caused some relief.

For the past one year, she c/o severe nasal stuffiness on catching cold. She would wake up at night because of not being able to breath and using nasal drop provides no relief. Have to breathe via mouth. This worsens at night while sleeping. Even when her cough and cold is gone her stuffy mose would stay as it is. While trying to exhale air forcefully she would c/o tearing sensation in nosal mucosa. Also, her mom noticed a very foul smell from her mouth.

This continued till Oct. She visited a Dr who said her tonsils are infected and prescribed antibiotics with nasal drop. After taking antibiotics for 20 days, the bad smell from her mouth went away and no relief from nasal blockage.

On Feb 15th she was taken to another Dr who did an Xray and diagnosed it as enlarged adenoids. Prescribed antibiotics and recommended Sx if medicines fail to cure it.

Dr recommended her to keep something in mouth and try breathing via nose. But, she is not able to do it.

This has affected her normal life also. Like she finds it hard to do dancing and exercises because of this stuffy nose.

Has a good appetite.

CHIEF COMPLAINT AND PT REQ.: c/o severe stuffy nose for the past 1 yr.

Pt only able to breathe via mouth

FAMILY HISTORY:

Mom - hypothyroidism detected 5 months after first delivery, took antidepressants for 2 months 1 yr after first delivery, migraine, GB Sx (5-6 yrs ago), tenosynovitis rt hand and wrist(6 months). Both babies via Cesarian delivery.

Father - reported no health issues

Younger Brother - reported no health issues

DAILY ROUTINE - wake up at 7 am gets ready for school, have half glass milk with horlicks after half n hr 1 roti with any sabji.. Go school at 8.15.. Have some tiffin at 10.30,comes back home at 1.30.. Have her lunch at 2 pm l rice dal and sabji like papaya and aloo.. Goes for tution and comes back at 5pm. Again milk with biscuit or chocos.. Have her dinner around 8.30 with sometimes oats with veg soups or sometimes roti sabji.. Sometimes eats eggs in the evening or any outside snacks.. Including chips and choclates in the evening time.. Goes to bed at 9.30 or 10 pm..

Saturday Sunday she goes for dance class in the evening for 2 hours..