Hormone replacement therapy

Patient is 40-year-old female who states that for the last few weeks she has developed an itchy rash on the back of her shoulders and along her neck line that she calls hives, although it appears to be more of a dermatitis. She has had this in the past. She states and it was persistent for months, however, this has been resolved for many years and now it suddenly has come back. She did switch her diet about the same time that this began to a no-carb diet. She has been eating more vegetables and fruits and trying to eat more healthy and feels that she may be developing food allergies. She also has noticed that strawberries, blackberries, peanut and peanut oil seem to cause an itchy throat and possibly be contributing to her rash. She also notices that she has eyelid swelling on the left side occasionally and is associated with unilateral headache and ear pain and a sore throat. She is not sure if this is due to allergies or something else. She has pursued a CT scan in the past and a rhinoscopy through ear, nose, and throat and everything turned out normal. She has been frustrated in the past as no one can seem to tell her what this is. It sounds to me like a type of possible migraine or cluster headache. She did about one month ago undergo a hysterectomy and then was placed on 80 mg of Progestin from the animal of a yam. She also is on DHEA 8 mg and an estrogen patch. She is concerned that these medications may be contributing to her rash.

She currently complains of nasal stuffiness only on the left side, sore throat, and itching inside ears. This occurs usually in the afternoon and is year round. She has had sinus infections in the past and frequent headaches, and frequent tonsillitis when she was a kid. She denies nasal polyps, TMJ, aspirin-induced nasal symptoms, nasal surgery, frequent bad cold, she has tried ibuprofen and nasal steroids with moderate relief. She did not use anything at this time. She did have CT scan of her sinuses done in 2015.

She does have frequent ear infections. She denies dizziness, lightheadedness, or hearing impairment.

She does have eye itching, redness, dryness, burning, and light hurting her eyes, eyelid swelling, and eyelid irritation. This occurs a lot of the time.

She denies any history wheezing or lung troubles or asthma. No further coughing spells. She has not had a chest x-ray in the last five years. She denies ever having an allergy evaluation done before.

ASSESSMENT:
1. Dermatitis, unspecified.
2. Allergic rhinitis.
3. Frequent unilateral headaches.
4. Concern for food allergy.
5. Allergic conjunctivitis.
6. Status post hysterectomy.
7. Hormone replacement therapy.

PLAN:
1. At this time, I discussed with that although we have positive on food allergy testing today, I do think these are false positive as she has tolerated all of these foods in the past. The foods that she was concerned about including soy and strawberries were negative. I do feel that she may be having an eczema flare and may be an atopic dermatitis. However, I am not sure of the specific dermatitis this may be. I also feel that it may be due to the replacement therapy, whether it is not enough of her replacement therapy or too much, however, I have a direct correlation between menopause and flare of eczema, and she may need to discuss with her OB/GYN doctor the possibility of utilizing or manipulating the doses to see if that will help clear up. However, if this is the case, it is a type of eczema that should respond to triamcinolone 0.25% ointment. I will have her apply this three to four times daily to help clear up the rash.
2. I also want her to try using fluticasone nasal spray one spray each nostril twice daily and Zyrtec 10 mg daily to see if this helps some of her unilateral nasal congestion, however, if she continues to have this problem, I do think she may want to see a neurologist to evaluate her type of migraine. She has pursued a CT scan for this and it was all normal, but it may be more of a neurological migraine rather than a sinus abnormality. We will follow up in one month to see how she is doing.

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