Heartburn

Patient is 22-year-old male who states that he has always had significant allergy troubles that began when he was a young boy in Wichita, Kansas. He did begin allergy shots for this. He also was diagnosed with asthma and that did significantly help. He has not required any asthma treatment since he was a kid and since he has been on the allergy shots. He has noticed he has had a recurrence in his allergy symptoms including nasal symptoms of sneezing, clear nasal discharge, clear nasal drainage, frequent nose blowing, nasal stuffiness, and mouth breathing. This occurs every day particularly between May and August. He just moved here in January to attend a BSU. He was also in Tahoe area in California and his allergies were not bad there. He denies troubles with sinus infection, nasal polyps, TMJ, frequent headaches, aspirin-induced nasal symptoms, nasal surgery, frequent bad colds, and frequent tonsillitis. This is moderate in severity. He has used Alertec. He has not tried any nasal spray. Alertec does help moderately.

He does have frequent ear infection, dizziness, lightheadedness, hearing impairment.

He does have some eye itching, redness, and tearing. He denies dryness, burning, light hurting his eyes, yellow discharge from eyes, eyelid swelling, or eyelid irritation. This occurs a lot of the time.

He denies any troubles with mild to moderate wheezing episodes or troubles with limiting his exercise or plays. He is a very fit young man but he is developing the tightness in chest. He says it starts when he is outside. When his allergies are significant, it just feels like chest tightness and it is hard to take a deep breath at the top of his inhalation and it tends to burn and ache. He has never really had this before and is concerned that this could be type of asthma. He has not tried albuterol for this or has required any treatment for asthma since he was a young boy. He denies frequent coughing spells, recurrent night cough, coughing up mucus, shortness of breath with exercise, blood in mucus, coughing on exertion, coughing with wheezing, coughing with laughing lying down or talking on the phone. He has not had a chest x-ray in the last five years.

He denies any allergic skin problems currently or in the past. He was evaluated before by Dr., he was six years old and did an allergy immunotherapy. He was shown to be allergic to grasses. He did have some marked improvement with the allergy shots. He feels that he was on the shot from about age 7 to age 12 years old and then he moved.

ASSESSMENT:
1. Acute allergic rhinitis.
2. Allergic conjunctivitis.
3. Mild intermittent asthma.
4. Heartburn.

PLAN:
1. At this time, patient would like to try medication really before pursuing skin testing to see if he can get positive relief with the medication.
2. He has not tried a nasal spray, so I wrote him a prescription for fluticasone nasal spray one spray each nostril twice daily to see if this will help his troubles during his allergy season. It may help prevent these chest tightness and shortness of breath episodes when his allergies are bad as well.
3. I also prescribed him an eye drop azelastine one drop each eye twice daily as needed for his ocular complaints.
4. I did give him an albuterol inhaler to try when he does have a chest tightness and shortness of breath while being outside. It does not seem to cause troubles when he is exercising or anything but he can try his albuterol and see if it clears it up. If it does, great and then it probably is associated with some intermittent asthma due to his history and family history and we will monitor that.
5. If he does not have relief with the inhaler and he continues have chest tightness event, I may consider the differential being GERD and controlling that or other etiology of this trouble. We will follow up as needed and he requests for that the rest of the spring and summer season. We may want to pursue skin testing in the future if he has troubles with his allergy symptoms.

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