Patient is 43-year-old female who has a history of seeing Dr. for many years in the past. The last time we saw her however was in September 2014. She has been treated for sinusitis infections with Dr. as well as food allergy and seasonal allergies. She was placed on allergy shots beginning in 2000. She did this for a few years and had some moderate relief with this. She however feels that her allergies have recurred as she was only on the allergy shots for about one and a half years. She does feel that the allergies have recurred since then. She currently complains of nasal symptoms including clear nasal discharge, frequent nose blowing that seem to be all year long indoor and outdoor although may be worse in the spring and fall slightly. She does currently have a sinus infection. She has had chronic sinus infections in the past. She uses Neilmed nasal rinses regularly. She states she gets about one to two of these infections per year and currently she is taking Z-Pak for this sinus infection and has been resolving. She denies any history of nasal polyp, TMJ, frequent headache, aspirin-induced nasal symptoms, nasal surgery, frequent bad cold, or frequent tonsillitis. She uses Allegra and Zyrtec in the spring through October for seasonal allergies with good relief. She uses sinus rinses but does not like to use corticosteroid nasal sprays. She has used these in the past.
She denies any frequent ear infection. She also denies any eye irritation, redness, tearing, burning. She does admit to have some eye dryness some of the time.
She denies any problem with asthma or wheezing episodes currently or in the past. She has never used albuterol inhaler. She has not had a chest x-ray within the last five years.
1. Allergic rhinitis.
2. Allergic conjunctivitis.
3. History of chronic and recurrent sinusitis infections.
4. Concern for food allergies.
5. Oral allergy syndrome.
6. Possible GERD.
1. At this time, patient still believes that it could be associated with a certain food that we may have not identified today for testing causing her increase in mucus. We did discuss that we may not identify specific IgE allergy to a certain food due to the history of mucus congestion being due to food allergy is not common. We generally see more immediate reactions of anaphylaxis, hives, and swelling and throat closing due to an allergy. She may have significant sensitivity to foods that cause an increase in this. It may also be reflux related although she still wants to pursue blood testing for food panel that she selected to further verify negatives on food allergy. We will also pursue respiratory region 15 panel to indentify seasonal allergies.
2. We will follow up in one month’s time. I will call her to discuss lab results with her. I did encourage her to use Zyrtec 10 mg once to twice daily to help reduce allergic reactions.