Hoarseness

Patient is 63-year-old female who has interesting history that may be presenting her complaints of hoarseness, difficulty taking, sore throat, ear pain and allergies. She has been a wildland firefighter her entire life and she now manages the medical station for wild fire fighting. She has been exposed to a very large amount of smoke inhalation in the past and possible chemicals burning in fires that could have been toxic. She was also burned in 1980s when a tree stump blew up near her and caused some throat burning and hospitalization for one week’s time. She has currently for the last couple of months had problems talking and throat hoarseness that brought her to Dr’s. office and there she did get scope and endoscopy done and there was some signs of scar tissue. She also has had a brain scan done due to problems forming words and everything was normal there, although they did see sinuses in that scan and they did show some abnormalities. She also has had lung and throat CT scan done and everything was normal other than a very small nodule on the left lung that they will be monitoring. She does also have a sleep study planned to see if there is any problem there. For the last two months she has had this continual cough from postnasal drip. She has always had allergies since she was approximately 28 years old. She states that this occurs year round and includes nasal symptoms of nose rubbing, clear nasal discharge, postnasal drip, nasal stuffiness, mouth breathing, frequent throat clearing, sore throat, hoarseness, decreased smell and snoring. She does have history of sinus infections although none that required antibiotics. She denies nasal polyp, TMJ, frequent headache, aspirin-induced nasal symptoms, nasal surgery, frequent bad cold and frequent tonsillitis.

She states that her symptoms are very severe and does not take any medications for this other than a nasal D extra moisturizing from Western Family. This appears to be a type of Afrin nasal spray that she uses on a regular basis. She denies any frequent ear infection, dizziness, lightheadedness or hearing impairment.
She does complain of eye symptoms of itching, redness, tearing, dryness, burning and light hurting her. She denies yellow discharge from eyes, eyelid swelling or irritation.

She did not have a history of asthma, wheezing or lung problems although she does currently have a cough that is continuous and chest tightness. She does have a history of pneumonia and bronchitis and seems to be very sensitive to lung infections. She has been exposed to a significant amount of smoke. She admits to having frequent coughing spells, recurrent night cough, shortness of breath with exercise, and coughing on exertion.

She denies any allergic skin problems including eczema or atopic dermatitis. She has been evaluated for allergies in the past by Dr. when she was in her 30s showing to be allergic to dust, feathers and almonds. She was on allergy shots for many years and had some improvement, although her symptoms seemed to recur when she stopped her shots.

ASSESSMENT:
1. Allergic rhinitis.
2. Allergic conjunctivitis.
3. Hoarseness.
4. Cough-variant asthma versus restrictive lung disease.
5. History of significant smoke inhalation.

PLAN:
1. At this time, we discussed the possibility of nasal decongestion causing rebound rhinitis medicamentosa. I encouraged her to discontinue this nasal spray and we will start fluticasone nasal spray two sprays each nostril twice daily.
2. I am also going to try QVAR two puffs twice daily to see how she response to corticosteroid inhaler to reduce her cough as well as her chest tightness.
3. We will follow up in two weeks’ time to see how these medications are helping and discuss possibility of starting allergy immunotherapy for long-term management and reduction of medications needs.

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