Upper airway cough syndrome

Patient comes in for a recheck. She states that this last week she had an episode of facial swelling. This occurred on Saturday. She woke up with hives after eating dinner of tacos a night before. The hives persisted throughout the day. She then again ate diner of tacos and then sushi at night and then after sushi when she was riding her bike home, she started having eye and lip swelling and it progressed to get worse and worse throughout the evening and until Sunday. She also had hives throughout the evening as well. She knows that she thinks that she has had hives intermittently through the last two years. It seems to flare when she has a lot of stress and also during her allergy season and has all been since she has moved to Idaho. She has been given hydrocortisone ointment for her face as well from Dr. to see if this gets clear up some of her facial rash. It seems to help at first, but then stopped helping. Her rash today kind of looks more like an acne to me. She does currently use Zyrtec 10 mg and Flonase daily to help with her allergy symptoms. She was tested in the clinic and was mostly negative for allergies except for cats, dog and dust mite and she does have a dog. She has not seen her primary care provider since she has been in Boise area and is concerned about may be pursuing blood work to rule out any other etiology of these hives and swelling, otherwise no changes.

ASSESSMENT:
1. Chronic idiopathic urticaria with angioedema.
2. Possible rosacea versus acne on nasal folds.
3. Local allergic rhinitis.
4. Local allergic conjunctivitis.
5. Upper airway cough syndrome.

PLAN:
1. At this time, I do feel that patient is having an acute flare of hives and angioedema that she may have been suffering from for the last couple of years. She does state that she gets intermittent hives reaction consistently since she moved here three years ago. She is having significant eye swelling and lip swelling. Currently, I would like her to start Allegra twice daily and to add a third dose in the afternoon if needed to see if we can control her hives and swelling at this time.
2. I do want her to pursue blood work. We will do thyroid antibodies and a CBC, CMP, angioedema panel, and ESR, CRP, and ANA to rule out any other etiology.
3. She was concerned about a food allergy, however, she has always eaten dinner of tacos and has had this type of sushi even though it was a new sushi restaurant, but it did seem to happen the next day and not merely after eating. She has also been using ibuprofen for neck pain. I did encourage her to stop using that as that could be a trigger as well. She has been able to use ibuprofen products in the past without problems, but while she is having this acute reaction, she will avoid this.
4. She will continue using Flonase daily for her nasal symptoms. We will followup in two weeks to see how patient is doing. If this is helping and to go over blood work.

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