Multiple chemical sensitivities

Patient is 36-year-old female who is here with her mother to discuss an allergy to chemical smells. She states that she has had various attacks from severity of mild to very major and these began when she was 14 years old. She was in a closed room where a man’s cologne bottle broke and she had a severe reaction to the significant smell in the air. She states that this causes throat tightness and lung tightness and trouble breathing. She also has panic attacks that are associated with this that are hard to control due to the trouble of breathing at these times. She had another event when she was 17 years old where some female sprayed a body spray in her face and caused her to have another throat tightness event that caused her to pass out and be hospitalized overnight due to this. She had multiple events after that that are either mild or major events. The last major event she had was on October 20, 2015 where she was at work and had a significant exposure to a chemical smell causing her reaction and she gave herself EpiPen because she could not control her reaction with albuterol and called 911 and sent to the emergency room. She generally uses albuterol one puff to two puffs as needed when she has these episodes and it seemed to resolve most of her problems, although sometime she cannot control and that is when she has EpiPen for emergency use. This has prescribed to her by Dr.. This is the only time she has used EpiPen. She denies any problems of nasal symptoms except for sneezing when first exposed to a chemical otherwise she does not have time postnasal drip, nasal congestion, mouth breathing, sore throat, hoarseness, decreased smell, decreased taste or yellow-green discharge. She denies any problems of sinus infections and has not had any nasal surgeries or had problems with frequent bad cold or frequent tonsillitis. She also denies any eye irritation of itching, redness, tearing, drainage, burning, eyelid swelling or eyelid irritation when around chemicals. She states that these reactions specifically hit her throat and lungs and nothing else is bothered. There are some chemicals that she can tolerate and is not bothered by and it is just hard to know which ones bother her. She is concerned for significant allergies to these chemicals.

She does not have history of asthma or wheezing problems other than with these certain episodes mentioned. She does not have frequent coughing spells, recurrent night cough, shortness of breath with exercise, coughing, wheezing or cough associated with the tightness in her chest. She has never needed prednisone to control wheezing episodes in the past.

She does have albuterol inhaler to use as needed for her exposure to chemicals. She denies any allergic skin problems like contact dermatitis or atopic eczema currently or in the past. She has never evaluated by allergist before.

ASSESSMENT:
1. Multiple chemical sensitivities.
2. Vocal cord dysfunction.
3. Possible mild intermittent asthma.
4. Anxiety with panic attacks.
5. GERD, well controlled.

PLAN:
1. At this time, I provided her some information on vocal cord dysfunction breathing exercise that she can practice at home and be very trained with these exercises so if she has a reaction she can find a safe place and perform these breathing exercises to get herself out of trouble. I also provided her an albuterol RespiClick 90 mcg one to two puffs q.4-6h. as needed to use at the time of distress as well as. She feels that that does seem to help a little. I also showed her paper bag technique to help with panic attacks that seemed to be triggered due to these events as well all in the goal to try to prevent calling paramedics and hospitalizations.
2. We discussed at length the difficulty of testing for specific chemical allergies and we had a good discussion about how these are triggers that cannot be tested as allergies today, but if we further have trouble controlling her exacerbations we can do further testing to identify any allergies that play. We also discussed a referral to a speech pathologist to help with these breathing exercises that she would like more help with this.
3. We will follow up in one month’s time to see how she is doing and if she gains better control of her chemical-induced breathing problems.

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