Concern for allergic reaction to Estrace vaginal cream

Patient is 68-year-old female who has a history of lots of seasonal allergies as well as medication allergies that seems to flare-up her nasal congestion as well as and bronchitis and chest tightness. She recently was started on Estrace vaginal cream to do 1 mcg twice daily and when she immediately started this that she was doing just fine but then the next day she would have increase in chest tightness and nasal congestion and was concerned that this may be due to this vaginal cream that she started. She then did not use it for couple days and it cleared up and she did not have any troubles. She then used it again and that was on Friday evening and then on Sunday morning she had a bad day with her chest congestion and nasal symptoms. She has not changed anything else in her environment, although she does have a positive history of having tree allergies as well as grasses and weeds and other medication allergies. She is wondering if may be this could be associated with increasing tree pollen in the air causing her symptoms. She does not like using medications. She has denied using albuterol in the past as well as any antihistamines on a regular basis or nasal sprays and would not like to start at this time. She would however like to be tested to this vaginal cream to make sure that she is not having an acute allergic reaction to this medication.

She does admit having nasal symptoms including itching, clear nasal, discharge, postnasal drip, nasal stuffiness occasionally, frequent throat clearing. This occurs in spring, summer and fall mostly. She denies having trouble with sinus infections. She denies nasal polyps, frequent headaches, aspirin-induced nasal symptoms, nasal surgery, frequent bad cold, or frequent tonsillitis. She had tonsillectomy when she was in fourth grade. She says her nasal symptoms are moderate. She uses neti pot regularly and that does seem to help give her relief.

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

She does have seasonal eye itching and redness but denies tearing, dryness, burning, light hurting her eyes or yellow discharge from eyes, eyelid swelling or eyelid irritation.

She has not had a history of asthma or wheezing troubles. However, she does feel that she has these acute chest tightness episodes and it is hard for her to catch her breath. This recently has been happening hours after using the new vaginal cream. She has had times where it may be her allergies that seem to trigger this or her seasonal allergies of the trees, grasses or weeds that trigger this. She had tried albuterol once in the past but it made her so jittery that she would never want to try it again and she does not like to use antihistamines or other medications. She denies having frequent coughing spells, recurrent night cough, coughing up mucus, shortness of breath with exercise, coughing on exertion, coughing when wheezing, coughing with laughing, lying down or talking on the phone. She has not had a recent chest x-ray in the last five years.

She did have some allergic skin problems last fall eczema on her neck. She was recently treated with an antibiotic due to a urinary tract infection and this was Keflex which actually cleared up her eczema as well surprisingly. This is the first antibiotic she has had in many years. She is scared of using antibiotics because of certain allergies. She did have allergy test 12 years ago by Dr. and shown to be allergic to trees, grasses, weeds dust, feathers, foods and some flowers. She was on allergy shots in the early 1990s and that helped improve her symptoms.

ASSESSMENT:
1. Concern for allergic reaction to Estrace vaginal cream.
2. History of allergic rhinitis.
3. Allergic conjunctivitis.
4. Possible mild intermittent asthma.
5. Anxiety.
6. Multiple antibiotic allergies.

PLAN:
1. At this time, I talked with that I do not believe that she is having a direct allergic reaction to this medication and it is an atypical presentation for this. I did encourage her to try continue using this product as she does feel that she would really like to be able to utilize this product for her troubles with her bladder and make sure that this works to start at a lower dose. I encouraged her to use a quarter of the amount that was given. So to start with a quarter mcg twice a week and see if that seems to help as well as not cause this increase in nasal congestion and shortness of breath and then the week after she can increase to half of the dose recommended which would be half a gm and then increase to the full if she does well on this.
2. I did discuss with her this is most likely due to tree pollen allergy as multiple trees have been blooming in the last few weeks and it seems to be more associated with the nasal rhinitis and shortness of breath and that she may want to try using antihistamine regularly for this as she is very averse to using medications, but I did encourage her to try using Zyrtec. She can start with half a tab daily at least through the spring season to see if that helps with her symptoms. I also gave her levalbuterol inhaler to use just in case. She has these acute shortness of breath episodes that does scare her, she is very anxious, and she will have this in case of an emergency to use.
3. If she has anymore concerns about allergies or poor control or breathing trouble, she will come and see me again so we can do more pulmonary function testing and rule out other allergy troubles. I would like to try to rule out some of her antibiotic allergies as well.
4. We will follow up as needed.

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