Peptic ulcer disease

Patient is 30-year-old man who has had very severe allergic rhinitis all his life, who feels it is unresolved. He has no relief with over-the-counter medications. He complains of sneezing, itching of the nose, nose rubbing, clear nasal discharge, postnasal drip, clear nasal drainage, frequent nose blowing, nasal stuffiness, mouth breathing, sore throat, clearing throat, hoarseness, decreased smell and decreased taste, itchiness inside of ears, and heartburn. He denies any yellow or green discharge in his nose. His family is concerned about his constant runny nose. This occurs every day. It is worse in the spring and fall. He does get frequent sinus congestion with infection that he does not need antibiotic. He has never had nasal polyps. He does complain of frequent headaches with associated allergy.

He tells us that his nasal symptoms are very severe. Currently, he takes Benadryl for relief of congestion. He has tried Nasacort and Flonase with not much relief. He has used Benadryl and Sudafed with very little relief.

Ears: He denies any seasonal ear infection. He does feel dizzy and lightheaded that he keeps hydrated sometime. He does have some ear infection as a child.

Eyes: He complains of itching, redness, tearing, dryness, burning, light hurting his eyes, and eyelid irritation. He uses over-the-counter allergy drops with moderate relief and these symptoms have been extreme problems.

He denies any wheezing, lung problems, asthma like symptoms, chest tightness, or wheezing after exertion or after infection.

He denies any allergic skin problems. He denies any possible drug allergies before.

ASSESSMENT:
1. Allergic rhinitis.
2. Allergic conjunctivitis.
3. Food allergies intolerance.
4. Peptic ulcer disease.
5. GERD.

PLAN:
1. Start Dymista nasal spray one spray twice a day, which aid in relieving rhinorrhea and other nasal symptoms.
2. Prednisone 30 mg per day for three days to relief inflammation.
3. Follow up in two to four weeks.

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