Concern for insect sting allergy

Patient is 40-year-old man who comes today to evaluate his allergies. He recently had cats introduced in the house about two months ago. Since that time he has had progressive worsening of his skin causing itching and some eczema-like lesions on his arms and neck. He states that it is very itchy and seems to be associated to when the cats are around him and lie on him or if he touch the cats. He has also had seasonal allergies. He complains of nasal symptoms including itching of the nose and roof of the mouth, nose rubbing, nose rubbing, postnasal drip, nasal stuffiness, mouth breathing, yellow-green discharge from throat, decreased smell, snoring, heartburn and belching. He has had some sinus infections in the past. He denies nasal polyps, TMJ, aspirin-induced nasal symptoms, nasal surgery, frequent bad colds or frequent tonsillitis. He does admit having some frequent headaches. He does use Sudafed occasionally for his nasal symptoms and gives him good relief. He does not use any antihistamines or nasal sprays. He denies any frequent ear infection.

He does admit having eye itching, redness, tearing, and burning. He denies dryness, yellow discharge from his eyes, eyelid swelling or eyelid irritation; this occurs some of the time.

He did have some childhood asthma. He used inhaler occasionally for wheezing. He had mild-to-moderate wheezing episodes and then currently during exercise he does have some shortness of breath. He is morbidly obese and acknowledges that it is more likely a restrictive course. It seems to be associated with tightness of chest. He does not use inhaler and does not feel like he needs an inhaler. He has never required steroids to help control wheezing in the past. He denies frequent coughing spells, recurrent night cough. He does have occasional shortness of breath with exercise. He does have some coughing on exertion, coughing with wheezing and laughing but denies coughing with lying down or talking on the phone. He also denies blood in mucus or coughing up mucus.

He does not have a history of allergic skin problems, although he does currently complain of eczema and itching of the skin. He has never been evaluated for allergies before.

ASSESSMENT:
1. Atopic dermatitis.
2. Allergic rhinitis.
3. Allergic conjunctivitis.
4. Concern for insect sting allergy.
5. Morbid obesity.

PLAN:
1. At this time, I encouraged to try using Flonase two sprays each nostril twice daily since he is around his cats and is having significant allergy problems. I also encouraged him to use Zyrtec 10 mg daily for reduction of itching as well as reduce his allergy symptoms to the cats in his immediate environment. We did discuss removing the cats in the bedroom as well as keeping the house clean with good vacuuming techniques to remove as much dander and dust mites as possible.
2. We discussed potential for long-term management with allergy immunotherapy. He is very interested in this as his daughter is on it and has been having some significant improvement and it could reduce his need for medications and better control his skin condition.
3. I also encouraged him to use Olivamine moisturizer with an atopic dermatitis action plan two days, to bathe every day, pat dry, and use moisturizer on a regular basis to hopefully encourage good skin barrier.
4. He would like to pursue skin testing for the various vespids to see how sensitized he is to the vespids and if he would qualify for doing vespid immunotherapy as well.
5. We will follow up with him for short appointment for the allergy immunotherapy and when he schedules an appointment to test for vespids.

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