Reflux, currently controlled

Patient is five-and-half year old boy who is brought in by his mother and father to evaluate for seasonal allergies. He has seen an ear, nose, and throat doctors recently who put him on fluticasone nasal spray to use one spray each nostril daily. Also he has had a history of acid reflux and uses some loratadine for this. Since he has been on these two medications he has had less incidences of cough and cold. He was having more frequent colds and cough prior to this but overall has been quite healthy. Mother does admit to having some nasal symptoms including stuffy nose, itching of the nose, frequent nose bleed, and heartburn. This seems to occur throughout the winter time but does not seem to occur during spring, summer, and fall.

They do deny sinus infections, frequent headaches, nasal surgeries, and frequent tonsillitis. They also deny frequent ear infections.

They do admit to him having some eye itching and redness but denied tearing, dryness, burning, light hurting his eyes, yellow discharge from eyes, eyelid swelling, and eyelid irritation which occurs at times.

They denied any wheezing or lung problems. They also denied any allergic skin problem. He has never been evaluated for allergies before.

ASSESSMENT:
1. Reflux, currently controlled.
2. History of frequent infection.
3. Allergic versus nonallergic rhinitis.
4. Possible allergic conjunctivitis.

PLAN:
1. At this time, the skin testing did not show that he can have seasonal allergies that we can identify today. However, we do not test for other thing and he may be reacting to some things and we did not test for. I do want him to continue using the nasal spray as this seems to help prevent more infection and reduce his stuffy nose.
2. I also encouraged him to continue with the famotidine as this may be contributing to nasal congestion as well.
3. We will follow up annually, if he is doing well and they will let me know if they feel he is more allergy symptom.

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