Mixed connective tissue disorder

Patient is 37-year-old female who comes in today to evaluate her seasonal allergies. She has always had severe allergies since she was about 10 years old. She does state that her troubles with her allergies cause her chronic congestion in her sinuses that lead to sinus infections usually yearly and thinks that immunotherapy would be best for her. She currently complains of nasal symptoms including sneezing, itching of the nose, nose rubbing, clear nasal discharge, postnasal drip, nasal stuffiness, sore throat, decreased smell, itching inside ears, and heartburn. This occurs every day. It is worse in the summer, but is bad in the spring and may be mildly in the fall and has relief in the winter. She does have occasional sinus infections one per year, TMJ, and frequent headache. She denies nasal polyps, aspirin-induced nasal symptoms, nasal surgery, and frequent tonsillitis. She does get frequent bad colds occasionally. This can be very severe. She has been using Alertec, AllerClear and she has used Flonase and Nasacort in the past, Zaditor, and currently using Xylitol based nasal spray that seems to help with her nasal troubles the most and Benadryl. She gets very little relief with treatment. She has had a CT scan of her sinuses years ago.

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

She does have eye itching, redness, tearing, dryness and burning, light hurting her eyes, yellow discharge from eyes, and eyelid swelling. She does have eczema as well as that occurs on her eyelids occasionally. This occurs a lot of the time. She denies any history wheezing or lung troubles. She denies frequent coughing spells or recurrent night cough, shortness of breath with exercise. She has not had a chest x-ray done in the last five years.

She does have occasional eczema on her arms and face. On her eyelid, she has used Elidel in the past and hydrocortisone ointment and that clears it up. She did have a previous allergy evaluation performed. She is highly allergic. She did do allergy shots as she tried them four years ago and did them for two years and has been off of it for two years. She did have moderate improvement with the immunotherapy, but not quite as good as her daughter’s was.

ASSESSMENT:
1. Acute allergic rhinitis.
2. Allergic conjunctivitis.
3. Atopic dermatitis.
4. Mixed connective tissue disorder.

PLAN:
1. At this time, I do feel that it would be best for patient if we retested her to evaluate where her sensitivities are to the Boise Valley and to pursue allergy immunotherapy for reduction of medication needs and long-term management. She did feel that the immunotherapy did help her troubles and especially allow the medications to be more effective while she was doing this treatment.
2. I did encourage her to use a medicated nasal spray, as this could be the best treatment for her including fluticasone, Nasacort, and to discontinue the antihistamines for a week for we can pursue the skin testing.
3. We will follow up next week for skin testing.

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