Concern for milk allergy

Patient is 23-year-old male who comes in due to a long-standing history of stomach complaints specifically severe abdominal cramping, diarrhea, and bloating and also seems to be associated with acne breakouts. He has noticed that this seems to occur due to intake of milk products. He states that this first began in 2012 in senior year high school. He was wrestling competitively and was told that his foot smelled very foul. He then was told by his coach that it could be what he is eating. He then cut diary out of his diet and it seemed to help resolve this trouble. He has since then tried to introduce diary into his diet including in the form of cheeses and milks and it immediately causes stomach cramping and bloating and also causes lots of acne around his mouth. He is concerned about food allergy to dairy products and likes to be tested today.

Patient denies any troubles with other allergies including seasonal allergies or nasal congestion. He denies any sinus infection troubles, any frequent headaches, frequent bad cold, or frequent tonsillitis. He denies nasal polyps, aspirin-induced nasal symptoms or nasal surgery. He denies frequent ear infection, dizziness, lightheadedness, or hearing impairment.

He denies any eye itching, redness, tearing, dryness, burning, light hurting his eyes, yellow discharge from eyes, eyelid swelling or eyelid irritation.

He denies any wheezing or lung problems currently or in the past. He denies any allergic skin problems currently or in the past. He has never been evaluated for allergies before.

ASSESSMENT:
1. Concern for milk allergy.
2. Irritable bowel syndrome.
3. Possible lactose intolerance.

PLAN:
1. At this time, I discussed with that this does not present as specific milk allergy and negative testing today further proves that. He may have severe lactose intolerance or trouble with milk products in a different way including via irritable bowel syndrome. I encouraged him to try using lactose-free milk and see if he seems to do fine with that. He has tried Lactaid in the past and it did not seem to help in fact it made it worse, although I encouraged him to try again because it has been sometime and see if that seems to help.
2. We also discussed probiotics that may help with irritable bowel syndrome and to see if he can utilize these as well as maintain a healthy diet to see if he can have better GI success. I did give him a sample of Align probiotic. He also has some probiotics that his family practitioner given him and he will give these a good try.
3. If he continues to have troubles with intolerance of milk as well as trouble with GI complaints with abdominal cramping, I encouraged him to go to see gastroenterologist so that they can further identify specific causes and make sure nothing else is going on.
4. We will follow up as needed.

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