Sympathetic dystrophy

Patient comes in today to evaluate her seasonal allergies with skin testing. I saw her on Friday November 20, 2015 to discuss her complaint of migraine, itching, and sneezing etc. We were unable to pursue skin testing at that time due to her being on Zyrtec but now she is currently been off Zyrtec for six days and has responded well, so we pursued with skin testing. At that time, I also provided her nasal spray Nasonex two sprays each nostril twice daily and she said she has had some relief from her postnasal drip, cough, and eye symptoms with this. She otherwise has no other concerns at this time. She did discuss with me that she has had albuterol inhaler in the past but has not needed for exercise-induced bronchoconstriction since 2009. She was concerned about some food allergies today causing triggers of migraines. We discussed at length slowly to see triggers without any allergic component. We did test for four different foods she thought might be significant including milk, beef, potato, and tomato, and may follow up with another full food panel in case she wants more answer for her choice.

ASSESSMENT:
1. Allergic rhinitis.
2. Allergic conjunctivitis.
3. Exercise-induced bronchoconstriction.
4. Migraines.
5. Mixed connective tissue disorder.
6. Sympathetic dystrophy.

PLAN:
1. At this time, I encouraged her to continue using the nasal spray as well as Zyrtec as needed for allergy symptoms as she finds this does help significantly improve her sinus pressure.
2. We discussed the fact that she could do allergy immunotherapy if she would like long-term management and reduction of medications need, although due to her mild allergy she would potentially have less successful rate with the immunotherapy compared to someone else who is very allergic.
3. We did discuss the milk allergy and that she could try to milk products out of her diet for two weeks time and see if some of her GI complaints resolve and then reintroduce slowly. She can tolerate cheeses fine and everything else, so I do not this is an IgE-mediated reaction although if she is having GI complaints she can certainly try removing from her diet and see if this helps.
4. We may follow up for more food testing in the future and as she would like to know any other food allergies, although she denies any history of food allergy or any food causing immediate itching, hives, swelling of throat, but she does have significant migraines triggered by certain foods.
5. We will follow up as needed and she will let us know if she wants to pursue more skin testing.

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