Bleeding disorder, unspecified

Patient has been having problems nausea and vomiting for most of her life, but has been getting worse lately. She states that pretty much anything she eats she gets nauseous right afterwards, specifically with certain products including dairy and meats and other hard to digest foods. She is unsure if this could contributes to or this is due to food allergy and now we would like to be tested today to see if there is any allergic response involved. She denies any hives, any swelling, anaphylaxis, or itching all over the body after ingesting certain foods. She recently had an endoscopy done approximately two weeks ago with biopsy. They show signs of inflammation. She was unsure of anything else of they noticed and they recommended for her to come here to see if there is any allergic problem.

She also complains of seasonal allergies that she had all her life. This includes nasal symptoms of sneezing, itching of the nose, nose rubbing, clear nasal discharge, postnasal drip, colored nasal drainage, frequent nose blowing, nasal stuffiness, mouth breathing,, frequent throat clearing, sore throat, hoarseness, itching inside the ears, frequent nosebleed, snoring, heartburn, and belching a lot. She states that these symptoms have been most of the year with worsening in spring and summer. She also gets frequent sinus infections approximately four to five years that required antibiotics. She also gets frequent headaches associated with this as well as the diagnosis of migraines. She does also gets frequent bad colds and frequent ear infections that seems to be associated with the sinus infections. She also has symptoms of dizziness and lightheadedness. She states that her nasal symptoms are severe and she has had tried Benadryl or other over-the-counter medication by mouth. She has not used any nasal sprays on a consistent basis, although has tried certain sprays in the past. She has never had a CT scan of her sinuses.

She also complains of eye irritation including itching, redness, tearing, dryness, light hurting her eyes, eyelid swelling, and eyelid irritation. This happens a lot of the time.She also has symptoms of mild to moderate wheezing episodes during her after exercise. She has been giving an inhaler in the past. She uses it possibly once a week but is not very often. She does use prophylactically before exercise and about 30 minutes before it helped with any shortness of breath associated with exercise. She does admit to some frequent coughing spells recurrent night cough, shortness of breath with exercise, coughing on exertion, coughing with and lying down. She states that she does not often get woken up from coughing, but occasionally will have coughing episodes that may be due to asthma. She also is getting worked up for GERD problems related to these coughing episodes as well as to her constant nausea.

She has had history of skin problems and when she was 4 years old, she would have eczema that they used steroid cream for and that helped area mostly on her outer arms. She also has a diagnosis of juvenile dermatomyositis and has had an associated butterfly rash with this.

She has never been tested for allergies in the past.

ASSESSMENT:
1. Intractable nausea and vomiting.
2. GERD.
3. Concern for food allergy.
4. Possible allergic rhinosinusitis.
5. Frequent infectious sinusitis.
6. Juvenile dermatomyositis.
7. Bleeding disorder, unspecified.

PLAN:
1. At this time, we provided her reassurance that she does not have any significant food allergies and we will let her gastroenterologist to know that food allergies should not be playing a role in her nausea and vomiting.
2. We will follow up next week to pursue skin testing for seasonal allergies and see how allergic she is and we can reduce her sinusitis infections and helped her fatigue and other nasal congestion and conjunctivitis.
3. We will continue to follow up with her heartburn and hopefully get records about her endoscopy and what that might have shown two weeks ago and continue to rule out any eosinophilic disease state.
4. When we pursue skin testing for seasonal allergies, we will further discuss treatment regimens for her nasal congestion, eye symptoms, and hives. I discussed the possibility of pursuing an ENT referral to look at her tonsils and adenoids. Her tonsils are 1+ hypertrophied today and could be reasonable to think that her adenoids may be hypertrophied as well contributing to her sleep apnea as well as some of her other complaints.
5. We will see her in one week’s time.

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