Eyelid swelling

Patient is 44-year-old female who comes today to address seasonal allergies as well as ocular swelling that has been occurring for the past two years and she has always had allergies in the past but they have been progressively becoming worse in the last two years. She did move from Tahoe to Idaho 10 years ago and noticed that she has had increasing seasonal allergies since she has moved here, although nothing has been similar to the last two years that she has had these increasing complaints. She states that she notes that she has nasal symptoms including sneezing, itching of the nose with mouth, nose rubbing, clear nasal drainage, postnasal drip, colored nasal drainage, frequent nose blowing, nasal stuffiness, mouth breathing, sore throat, yellow-green discharge, decreased taste, inching inside ears, snoring, heartburn, and belching a lot. She states that it has been constant since March 2015 but usually has relief in the wintertime. She does use Flonase one spray each nostril twice daily currently, although she feels that it is starting to burn her sinuses and disrupts her taste and smell.

She has had many infections this year including sinus infections and viral infections that seemed to linger and not heal well. She has been on four to five antibiotics doses for sinus infections that do not go away. She has also been on more antibiotics for diverticulitis event that she is struggling with. Her last dose was amoxicillin that she finished a few days ago and it was a 10-day course. Prior to that in September she was on azithromycin for 20 days. She has also had three bouts of prednisone in the past for her eye swelling and severe ocular complaint that seemed to work very well to resolve all her symptoms.

The last time she had steroids was in August. She has also used Zyrtec 10 mg daily as well as Benadryl two to three tabs at night with some relief. She does admit to having frequent sinus infections and frequent bad cold. She denies any nasal polyp, TMJ, aspirin-induced nasal symptoms, or frequent tonsillitis. She states her nasal symptoms are severe.
She also complains of eye irritation including itching, redness, tearing, burning, yellow discharge from eyes, eyelid swelling, and eyelid irritation. She has not seen ophthalmologist for this. Her eyes are currently tearing in the office today.

She does admit to having dizziness and hearing impairment. She does have a history of problems with cerumen impaction and states that she feels that she has an impaction today. She denies any frequent ear infections or lightheadedness.

She does admit to some mild-to-moderate wheezing episode. She was diagnosed with asthma at age 14 which seemed to be exacerbated in spring and fall. She has a Proventil inhaler for as needed and she does not need this often. She was on that maintenance dose inhaler in the past when she was young but she never needed steroids due to asthma exacerbation. She states that she does have wheezing associated with tightness in chest and it occurs sometimes when she feels sick but mostly when she is around animals. She does admit to frequent coughing spells, coughing up mucus, coughing and wheezing, and coughing with lying down although not currently. She has not had a chest x-ray within the last five years. She denies any allergic skin problem such as eczema. She has never been evaluated for allergies in the past.

ASSESSMENT:
1. Allergic rhinitis.
2. Allergic conjunctivitis.
3. Eyelid swelling.
4. Recurrent sinusitis.

PLAN:
1. Today, we will start prednisone 30 mg for three days to reduce inflammation that is going on her eyes and help with irritation.
2. We will also start QNASL one spray each nostril twice daily to help with inflammation and sinuses.
3. I encouraged her to discontinue Zyrtec and Benadryl for skin testing next week. She can take Benadryl two days before testing but not any closer to testing. We would like to further determine the etiology of her symptoms and pursue skin testing to know exactly how allergic she may be.
4. At next visit, I will give her some Pazeo eye drops as well to see if that helps her ocular complaints.
5. We will follow up in one week’s time to pursue skin testing.

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