Acute pharyngitis

Patient comes in for a recheck. She states that she has been having bad colds that start with a sore throat and turn into a bad cough with a green mucus production. She has been on an antibiotic dose Augmentin for seven days prior for this and it did clear up very nicely. That was on May 16 when we saw her last by Dr.. She states that this most recent infection started last Wednesday and has progressed like it usually does into her sinuses and causing the green mucus drainage and coughing. She is concerned that this also could be due to allergies and might be more than she is having chronic inflammation because of allergies leading to these infections. She was tested in 2009 for Dr..She was only positive to sagebrush and dog at that time. She does get frequent infections lately. Mom is a little concerned about it as she is going off to college this year to be in the dorm rooms and is worried she will be getting sick a lot there. Currently, she is taking Zyrtec-D, vitamins, and an herbal supplement called counterattack to help with her symptoms. She has not tried any nasal sprays.

ASSESSMENT:
1. Acute upper respiratory infection with cough.
2. Allergic rhinitis.
3. Acute pharyngitis.

PLAN:
1. At this time, I do feel that is probably responding to environment with allergy triggers causing a chronic inflammation in her sinuses leading to these infections. I do want her to use Flonase one spray each nostril twice daily to see if we can do this every day throughout the season and help prevent some of these frequent infections from occurring.
2. I also want her to have clarithromycin for 14 days to clear up her sinuses and get her feeling better. If she continues to have troubles and this does not clear up, she will come back and see me. I do want her to consistently be taking Zyrtec and Flonase every day so that we can prevent these infections. We may want to pursue immunodeficiency workup if patient continues to have troubles with frequent infections.

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