Possible malar rash

Patient is 7-year-old girl brought in by her mother to evaluate for possible allergies. She states that about three to four years ago she noticed every spring she started having significant stomach pains and would feel very sick and have headaches and be drying up and be nauseated. She noticed that it would happen for the spring and then get better and she would not have troubles again until the next spring. This happened three springs in a row and then since this last fall she developed these symptoms again and she has had these symptoms that are consistently about every other day to every four to five days since this last fall. In January, they tried doing a diet elimination. They have been off gluten and she has had some relief in her tummy aches and this red rash that seems to occur. She says she gets a little red bumps on her arms and on her torso and cheeks and this takes about a week to resolve. Mom has also noticed a type of malar rash along her cheeks and under her eyes after she has gluten. She does occasionally have troubles even though she is on a gluten-free diet now. They do feel that egg may be causing troubles as well. Her stomach pains can be so bad that it causes her to miss school. She has missed four days in the last month. At those times, she does have a low-grade fever and this malar rash as well as stomachaches. She does get diarrhea occasionally, but they have not noticed any bleeding or blood in the stool.

She does state sometimes she has a postnasal drip, runny nose, and wakes up with the dry mouth. She did get tonsillectomy when she was 4 years old. She broke her nose when she was 3 and that is when they noticed that they probably needed to get the tonsils and adenoids out. They deny any troubles with sinus infections and nasal polyps. She does get frequent headaches. She states it is a kind of on both sides around her forehead, but not unilateral. She denies aspirin-induced nasal symptoms or nasal surgery. She might have some frequent bad cold. Mom is not sure. She does get some frequent urinary tract infections, which her mother did too at that age. They deny frequent tonsillitis. She denies frequent ear infection, dizziness, lightheadedness, or hearing impairment.

They deny eye itching, redness, tearing, dryness, burning, eyelid swelling, or eyelid irritation.

They deny any history of wheezing or lung troubles.

ASSESSMENT:
1. Possible allergic rhinitis.
2. Possible allergic conjunctivitis.
3. Abdominal pain unspecified.
4. Concern for gluten or egg allergy.
5. Possible celiac disease.
6. Possible malar rash.

PLAN:
1. At this time, I discussed with patient and mom that she is not exhibiting any allergies today, however, we may have missed some allergies that we did not test for due to her presentation. I would like her to try fluticasone nasal spray one spray each nostril daily to see if this does in fact help some of her postnasal drip and nasal stuffiness.
2. We will do some blood work to determine if celiac disease is present. I also want to test ANA, ESR, and CRP to rule out any other autoimmune etiology for her malar-type rash her mom is describing to me, however, I was not able to see this visually today.
3. We also will test for respiratory region just to see if we have missed any positives on allergies today.
4. I will call mom with the test results and we may followup thereafter to see what might be next to evaluate patient’s stomach pains and other symptoms.

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