Allergic rhinitis

Patient is 31-year-old male, who is here today to address his seasonal allergies and nasal congestion as well as itching. he states that ever since he was approximately 17 years old, he started having itching of the skin and dermatographism as well as nasal symptoms including sneezing, nasal stuffiness, mouth breathing, decreased smell, decreased taste, itching inside his ears, and snoring. These sometime seem to occur every day and worse at night. He states that when he was approximately 26 years old, he moved to Boise and started having increasing complaints of these symptoms. He then went to ENT Dr. Clinton where they performed a scope and CT scan and found nasal polyps and signs of chronic sinusitis. He did not pursue surgery at that time, but was given an oral prednisone dose taper and given budesonide nasal steroid that did help resolve his symptoms at that time. That was in 2013. He has not been using any nasal sprays or anything for his nasal polyps since that time.

He denies any sinus infection requiring antibiotics in the past or TMJ, but he does get frequent headaches and he also denies aspirin-induced nasal symptoms, nasal surgeries, frequent bad colds or frequent tonsillitis. In the past, he has used antihistamines daily as well as budesonide nasal spray. He also uses Mucinex, but seems to get some moderate relief.

He denies any frequent ear infection, dizziness, lightheadedness, or hearing impairment.

He does have itching in the eyes but denies any redness, tearing, dryness, burning, eyelid swelling, or eyelid irritation.

He has never had any wheezing or lung problems or any history of asthma or need for albuterol inhalers.
He denies any allergic skin problems other than the itching and dermatographism. He has noticed that he used to get hive-like reaction when exposed to heat or with exercise, but does not get that as long as he continues to take Aller-Tec daily. He has never been evaluated for allergies in the past.

ASSESSMENT:
1. Allergic rhinitis.
2. History of nasal polyps.
3. Pruritus.
4. Dermatographism.
5. Possible allergic urticaria.

PLAN:
1. At this time, we will start QNASL 80 mcg one to two sprays twice daily to help his nasal congestion and hopefully reduce his nasal polyps and give him some relief from this congestion.
2. Continue with Zyrtec. I encouraged him to take tablets per day morning and night to help reduce his skin itching as well as his heat-induced urticaria like symptoms and dermatographism.
3. I encouraged him to do allergy immunotherapy in the form of injections or Grastek to help reduce his allergic exposures as this will help overall reduce his need for surgery for his nasal polyps.
4. I also encouraged use of Singulair to combat all other mast cell degranulation that could be increasing his nasal polyp severity, but he declined today. He does not want to take that much medication. We will start with the QNASL and discuss that more at later time.
5. We will followup in one month’s time to see how QNASL is working as well as the Zyrtec at higher doses for his skin complaints and further pursue other management techniques to give him adequate control with his nasal polyps.

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