Possible celiac disease

Patient is 60-year-old female who comes in to try to identify seasonal and food allergies. She states that she does have this kind of chronic postnasal drip and runny nose particularly at night when she is lying down and does notice that it seems to be in the spring, but also can be year around. She currently complains of nasal symptoms of sneezing and sore throat. She has felt in the past that she has had breath problems when the chenopod count is high. She has had occasional signs of infection. She denies nasal polyps, TMJ, frequent headaches, aspirin-induced nasal symptoms, nasal surgery, frequent bad colds, or frequent tonsillitis. It is moderate in severity. She uses antihistamine such as Claritin. She gets good relief with this. She has not used a nasal spray.

She denies frequent ear infection, dizziness, lightheadedness, or hearing impairment.

She does have eye itching, redness, tearing, and burning. She denies dryness, light hurting her eyes, yellow discharge from eyes, eyelid swelling, or eyelid irritation. This occurs some of the time. She does feel this is the most irritating symptom she has.

She denies any history of wheezing or lung troubles. She denies frequent coughing spells, recurrent night cough, and shortness of breath with exercise. She has not had a chest x-ray in the last five years.

She denies any allergic skin problems. She has not had previous allergy evaluation.

ASSESSMENT:
1. Allergic rhinitis.
2. Allergic conjunctivitis.
3. Chronic postnasal drip.
4. Concerns for food allergy.
5. Possible celiac disease.

PLAN:
1. At this time, I talked with that she does have significant seasonal allergies particularly to grasses and weeds and would benefit from antihistamines or nasal sprays consistently through her pollen season to help for symptom relief.
2. I did discuss allergy immunotherapy being a good treatment for her for reduction of medication needs and long term management and she will consider this option.
3. I did provide her with a fluticasone nasal spray prescription to use one spray each nostril twice daily to help clear up her sinuses. If she develops any type of sinus infection or is not getting relief with this, she will contact me and let me know.
4. We will follow up with patient as needed.

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