Tom

Tom, a nine-year-old male, was initially seen in May 1996 with the chief complaint of constant post-nasal drip, hyperactivity, and insomnia after eating certain foods. Tom had been a healthy baby whose speech, motor skills, and coordination were all normal.

Post-nasal drip started approximately three years before the first office visit. Throat itching, clearing and coughing, especially in the morning, were increased secondary to post-nasal drip. An adenoidectomy in May 1995 helped, but symptoms increased by March 1996. There also was a history of laryngitis approximately twice a year [especially in the spring], recurrent ear ringing, severe headaches approximately once per month, and "sleeplessness" especially after ingesting tomatoes or foods with red dye. In addition, Tom was experiencing decreased focus and jumping out of his seat in the classroom. It was thought that low-dose Ritalin would help the ADD problems. Of significant concern was the problem with mood swings at home with Tom having said, "I want to kill myself" several times prior to May 1996.

Physical examination was completely normal except for allergic shiners and an allergic appearance to the nasal membranes.

For the past year, Tom has been treated for his allergies to 24 inhalants (grasses, trees, weeds, dust products), 22 molds, and 21 allergic foods.

At quarterly office visits, Tom has shown significant improvement. At the most recent office visit in early June 1997, his problem with constant post-nasal drip for the previous three to four years was markedly diminished. Problems with insomnia, headaches, laryngitis, ear-ringing, behavior and most important, self-esteem, have dramatically improved over the past year. In school, his concentration is better but there is still room for improvement.

The plan at the present time is to continue a good nutritional diet and Sublingual Immunotherapy. Options for the future include Ritalin dosage increased in the future if his ADD problem continues or switching to another stimulant medication that may be more effective.

This child is an excellent example of a patient with allergies, ADD, and until one year ago, low self-esteem. By controlling his allergic problems, Tom's physical and emotional health have dramatically improved in just one year. Tom still has an ADD problem which will continue to be addressed in the future.

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