Vasomotor rhinitis

Patient comes in today for a followup on her last encounter on 09/16/2015. At the time of last visit, she had continued having problems with sinus drainage and coughing up colored sputum. We gave her a 21-day course of antibiotics before that. She feels that the mucus color has changed from green to clear for a couple of days and then this came right back. She does states that she does feel a little better than she did before but she is still having green discharge today in the morning specifically and it clears throughout the day. She is taking Flonase two sprays each nostril twice daily and gets some added relief with this. She is still constantly complaining of postnasal drip causing cough where she is coughing up sputum and increased mucus secretions. She still feels a lot of pressure in her sinuses and it feels like an infection to her. She also was started on Arnuity at last visit to see this would help her shortness of breath at night. She takes one puff in the evening and this has been helping her shortness of breath and has not had problems with breathing since we started Arnuity. She also uses ProAir only once in a while, while she is outside gardening. She does not use any of this medication and has not needed it since I saw her last. We also pursued a CT scan and chest x-ray at last visit and the x-ray showed that her lungs are clear and everything was normal. The CT-scan showed very mild mucoperiosteal thickening but no evidence of acute or chronic sinusitis. We have tried prednisone in the past as well on 08/25/2015 and this did not seem to give her much help she felt.

ASSESSMENT:
1. Concern for chronic sinusitis.
2. Postnasal drip.
3. Cough.
4. Vasomotor rhinitis.

PLAN:
1. At this time, we would like to start QVAR using a baby nipple to administration in her nose to see if this better helps for postnasal drip. We are hesitant and starting her antibiotic at this time because she has had multiple doses of antibiotics within this last year to try to treat this and nothing seems to be helping in the long-term.
2. We will follow up in 10 days to see if this change in nasal spray seems to help her nasal symptoms any better than Flonase does. We will also continue her on Arnuity and ProAir to continue to reduce her shortness of breath especially at night.
3. We also talked about heartburn possibly playing a role. She does have severe GERD and takes lansoprazole 30 mg one to two times daily. She states she has been doing this mostly once a day and perhaps we need to reassess this and make sure her GERD is completely controlled although she does feel that does today.

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