Patient is 12-year-old female who is brought in by her mother to evaluate her for seasonal allergies as well as her asthma. she has always suffered from chronic runny nose and nasal stuffiness since she can remember. She states that she currently has nasal symptoms of sneezing, itching of the nose, nose rubbing, clear nasal drainage, nasal stuffiness, mouth breathing, sore throat, decreased smell, snoring, and heartburn. She has been on multiple medications in the past for this and currently montelukast, loratadine and omeprazole and she
just does not know what is working and what is not working. She was recently placed on omeprazole about one week ago and has not noticed difference with her heartburn and stomachache but has not been on it for long. She denies problems with sinus infection, nasal polyp, TMJ, aspirin-induced nasal symptoms, nasal surgery, frequent bad cold, or frequent tonsillitis. She does have frequent headaches in the front area and temple. She has used fluticasone in the past as well as but she has a hard time being compliant with the medication. She states that when she does use it does seem to help.
She denies any frequent ear infection or hearing impairment. She does admit having some dizziness and lightheadedness.
She does have eye itching, redness, tearing, dryness, and burning. She denies light hurting her eyes, yellow discharge from eyes, eyelid swelling and irritation.
She has history of wheezing and lung problems. She was diagnosed with asthma when she was young and has been on QVAR, albuterol as well as menaquinone to help with her breathing trouble. She does admit having mild to moderate wheezing episode that does limit her exercise and play associated with chest tightness. She has not required any prednisone to help with asthma flare. She currently does admit to frequent coughing spells, shortness of breath with exercise, coughing on exertion, coughing with wheezing, coughing with laughing, and coughing with lying down. She denies recurrent night cough, coughing up mucus, blood in mucus, or coughing with talking on the phone. She is on QVAR 40 mcg two puffs twice daily but she has been just using it one puff daily and actually do as well. Mom is unsure what is helping and what is not and wants to try to reevaluate all the medications. She has not had a recent chest x-ray within the five years. She has had history of eczema a child on her legs and currently controlled. She has never been evaluated for allergies before.
1. Allergic rhinitis.
2. Allergic conjunctivitis.
3. Possible mild persistent asthma.
4. Abdominal pain, generalized
5. Nausea and vomiting.
1. At this time, I discussed with mother that I do feel that she needs to be on asthma medication including QVAR 40 mcg to use one to two puffs twice a day and albuterol as needed prior to exercise and gym class and other times. She is currently complaining of shortness of breath and trouble breathing most of the time during the day.
2. I also encouraged her to use Nasonex one spray each nostril daily and cetirizine 10 mg daily. I told her to discontinue montelukast and loratadine. We will see if she can be compliant on this medication. She told me that she really wants to try hard to do this to help with her symptoms and to prevent the need to do allergy immunotherapy for her symptoms.
3. We did discuss allergy immunotherapy to help reduce medications need as well prevent the Atopic March as well as asthma severity. We will see how this summer goes and if mom wants to pursue allergy shots she will let me know.