Vocal cord dysfunction

Patient comes in for a recheck. We have not seen her since October 2014. She has seen Dr. in the past. Currently, her asthma is acting up she says. She states she is using her albuterol inhaler about four times per day. She has lots of coughing with mucus. She feels that she has this severe drainage at night when lying down from her sinuses. It is always clear. She feels that she is coughing due to the postnasal drip that is occurring. She has tried Singulair in the past that did not help at all. She has also been on QNASL and Patanase; however, she does have glaucoma and she was concerned about this, so she was to stop the QNASL. She feels like she can hear herself wheezing. It seems to be up high in the throat and this seems to occur when her sinuses are draining so much. She has had a history of a laparoscopic fundoplication for her heartburn and that has been resolved. She also had nasal surgery in 2013 by Dr. and that has significantly helped. She did have deviated nasal septum repair. She is not on any maintenance inhalers and has never been on any maintenance inhalers before. Otherwise no changes.

ASSESSMENT:
1. Upper airway cough syndrome.
2. Allergic rhinitis.
3. Allergic conjunctivitis.
4. Possible chronic asthma.
5. Cough.
6. Vocal cord dysfunction.

PLAN:
1. At this time, I do feel that patient may be having more vocal cord dysfunction than wheezing from asthma. The albuterol does not really seem to help too much. She does have a cough that seems to be due to postnasal drip. I do think this is more in her sinuses than in her lungs. I did not hear any wheezing today.
2. I do however want her to try using Dymista nasal spray one spray each nostril twice daily for the next couple weeks to see if this will help. I know she does have glaucoma, so I do not want to exacerbate that, but I do feel that she may benefit from this. If she does not have much improvement in the next couple of weeks, she is to start Symbicort as well two puffs twice daily to see if this in fact helps her cough and then I can tell if it is coming from her sinuses or the lungs.
3. I did give her some breathing exercises for vocal cord dysfunction, so she can try practicing these and see if it would resolve some of her wheezing.
4. She does have a positive allergy history and on skin testing was severely allergic; however,. She has been trailed off lisinopril in the past. It did not seem to improve her cough, so she is back on it. I do think all this may be of an allergic source. We will follow up with her next month and see if any of these changes have improved her symptoms.

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