Aphthous stomatitis

Patient is 15-year-old girl who comes today to evaluate allergies as well as a constant headache, nasal congestion, and mouth ulcers. She does also get occasional hives on her neck and torso. She was living in Arizona for eight months when she got allergy testing the first time due to these types of complaints. They did show positives to peanuts and tomatoes for food allergy and she has been avoiding those and has been having much better relief of her mouth ulcers. She also was tested positive for multiple trees, grasses, and weeds. This was done by blood testing. She did not have any skin testing performed at this time. Currently, she states for the last two months her headaches have recurred. She has had headaches everyday. They do not seem to be associated with any auras or vision loss or floaters. They do not cause light sensitivity and are not so severe that she cannot do anything throughout the day, but it is just an underlying mild headache in the temporal area and frontal area of her head that does not seem to go away. She does not use much medication for these, but when she does, it does not seem to help.

She complains currently of nasal symptoms with nose rubbing, itching of the nose, and nasal stuffiness. She denies any yellow or green discharge in throat. She states that there is some seasonal variation to this mostly in the spring and summer. She does have some sinus infections and feels that she gets sick all the time. She does get some frequent bad colds. She denies nasal polyps, TMJ, and aspirin-induced nasal symptoms. She did have a tonsillectomy and adenoidectomy in 2008. Her nasal symptoms are very severe. She has tried nasal sprays intermittently, but they do seem to bother her a lot and she has not been very compliant with these. She has also used antihistamines long time ago and they did seem to work, but had not used them regularly.

She denies frequent ear infection, dizziness, lightheadedness, or hearing impairment.

She admits having eye itching and tearing. She denies redness, dryness, burning, light hurting her eyes, yellow discharge from eyes, eyelid swelling, or eyelid irritation.

She denies nay history of wheezing or lung problems. She also denies any allergic skin problems except for the hives that seemed to occur just intermittently on her neck and resolved without treatment.

ASSESSMENT:
1. Allergic rhinitis.
2. Allergic conjunctivitis.
3. Concern for multiple food allergies.
4. Aphthous stomatitis.
5. Keratosis pilaris.
6. Headaches.
7. Sleep apnea.
8. Possible GERD.

PLAN:
1. At this time, I talked with that she may have significant allergy symptoms that are contributing to her headaches, fatigue, and nasal congestion. I do want to try Nasonex nasal spray, one spray each nostril twice daily consistently as well as cetirizine 10 mg daily to see if this helps resolve some of this.
2. I did discuss with her that she is negative on skin testing today. So, I do not believe she does have any food allergies and I do not think that they are associated with her aphthous ulcers. I would like to continue monitoring this to see if they continue recurring or if they seem to resolve and she is working on her diet. They have removed caffeine from her diet and she is going to try removing other foods that seem to trigger aphthous stomatitis like sugars.
3. She is interested in long-term management treatment plan of allergy immunotherapy and we will begin that shortly. So, we can desensitize her to allergens so that she can have better relief. We are hopeful to reduce her sleep apnea troubles. She was significantly congested today on physical exam. We will followup in one month to see.

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