Patient is here for a recheck for her complaints of rhinitis. She is a very pleasant older woman who we have not seen since 2013. At the time of our last visit, we had given her a prescription for nasal Atrovent 0.6%. She uses this two times daily one spray each nostril. This seems to be quite effective for her on most days although in the wintertime, she tends to have more postnasal drip and hoarseness from being cooped up in her apartment with her animals. She does have significant allergies to cats and dogs and she does have a cat and dog in the home. She also has a history of other seasonal allergies. She used to be able to keep her cat and dog out of her bedrooms, but now she lives in a studio apartment and therefore the cat and dog roam around at large in her home. However, she has not had a lot of more complaints since her new living arrangement. She has moved into her apartment 14 months ago and still feels that she has good control of her allergic rhinitis most days. She is here as a preventative appointment so that she can better control her rhinitis if it is occurs this winter. She was thinking may be allergy immunotherapy may be a good choice for her to help with this winter although I discussed with her that this is a long-term medication that takes longer than the next couple of weeks to start working very well and it may be best to try other medical interventions previous to the immunotherapy especially since she is an older lady.

1. Allergic versus mixed rhinitis.
2. Postnasal drip.
3. Hoarseness.

1. At this time, since she does have significant allergies to her pets and she is only on Atrovent, I would like to try Dymista one spray each nostril daily instead of the Atrovent and see if she gets better relief with this medication. We discussed that this medication can unfortunately be expensive and if she does find better relief and enjoys the single spray better, then we could do a two sprays of the active ingredients and Dymista for the reduction of cost associated with this change.
2. I continued to encourage her to reduce her pet dander exposure as much as possible by keeping her home clean and utilizing HEPA filters, vacuum bags or an air filter to help.
3. We will see Bobbi in two weeks’ time and see how she likes the Dymista and if she would like to make that nasal spray change. At that time, we can further discuss immunotherapy if she still is interested in trying this option although given her age and minimal complaints today, I feel that we can manage her symptoms without the immunotherapy.


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