Depression with insomnia

Patient is 39-year-old female who comes with significant allergy symptoms that began approximately one year ago becoming a constant irritation for her. She feels that she first noticed allergies about two years ago that will kind come and go and now she feels that she just has constant nasal drip in the back of her throat as well as blowing her nose constantly. She does complain of nasal symptoms of sneezing, itching of nose, nose rubbing, clear nasal discharge, postnasal drip, nasal stuffiness, mouth breathing, frequent throat clearing, sore throat, hoarseness, decreased smells, decreased taste, and itching inside ears. She states this occurs every day and does not have much seasonal variation. She has had some sinus infections. She denies any nasal polyps, aspirin-induced nasal symptoms, nasal surgeries, frequent bad cold, or frequent tonsillitis. She states that her nasal symptoms are very severe. She has tried several over-the-counter medications and is currently on Singulair, two nasal sprays of Astelin and fluticasone. She uses Astelin one spray each nose daily and fluticasone one spray each nose twice daily. She also uses Pataday eye drop and various over-the-counter antihistamines. They do seem to help moderately.

She does complain of swelling in her internal ear canal, irritation, and itching in the ears. She does state that this seems to be associated with her increased nasal congestion and allergies. She has had to use antibiotics for frequent ear infections. She does have some dizziness, lightheadedness, and hearing impairment associated with this.

She does admit to having eye itching, redness, tearing, dryness, burning, light hurting her eyes, and eyelid irritation that occurs a lot of the time.

She denies any history of wheezing or lung problems. She does not complain of recurrent night cough, shortness of breath with exercise, or frequent coughing spells. She denies any allergic skin problems except for around her nose which she is constantly blowing her nose and she has developed a type of dermatitis. She has been given triamcinolone cream for her face that seems to be helping resolve this irritation. She has tried metronidazole gel as well and that did not seem to be anything for her. She has never been evaluated for allergies in the past.

ASSESSMENT:
1. Allergic rhinitis.
2. Allergic conjunctivitis.
3. Dermatitis around nasal fold.
4. Ear pain, unspecified.
5. Depression with insomnia.
6. Allergy to walnut and pecan versus oral allergy syndrome.

PLAN:
1. At this time, I discussed with patient that she would be a very good candidate for allergy immunotherapy for long-term management as it appears that her symptoms and complaints do seem to be associated with severe allergies. We did discuss lifestyle modifications as well to keep the cat out of her bedroom as well as reduce dander in air by air purification and keeping a clean house and also closing window during pollen seasons.
2. I also encouraged her to continue using Astelin and fluticasone. I did encourage her to increase the dose doing Astelin one spray each nostril twice daily and fluticasone five minutes after Astelin one spray each nostril twice daily. I also encouraged her to use cetirizine or fexofenadine daily for allergy symptoms. She can continue with Pataday.
3. Triamcinolone 0.1% cream for face does appeared to be working so she will continue to use this. I did discuss that she will only use for two weeks and then have one week break. If she continues to have rebound, flares or trouble resolving this, she will let me know so we can get her the appropriate treatment.
4. We will call her with financial estimates of the allergy immunotherapy and if she would like to pursue we will begin as soon as possible. We will follow up as needed.

Advertisements

Leave a Reply