Laryngopharyngeal reflux disease

Patient is 78-year-old female who states that for the last month particularly she has been having increased possible allergy complaints. She states that she has a very runny nose all the time and has had this very dry cough lately. She feels that there is a type of lump in her throat that she had to finger to constantly clear her throat and feels that she has a hard time swallowing. She also has had some ear popping and clinging in the mornings as well. She does feel that mucus runs down the back of her throat and she is kind of clearing that and coughing up some cleared mucus occasionally.

She currently complains of nasal symptoms including clear nasal discharge, postnasal drip, frequent nose blowing, and frequent throat clearing. This occurs every day. It has been the worst this last spring and the last month. She does have a history of frequent sinus infections in the past, but she has not had any trouble with that in quite some time. She also has frequent headaches. She denies nasal polyps, TMJ, aspirin-induced nasal symptoms, nasal surgery, frequent bad cold, or frequent tonsillitis. This can be severe. She was given a nasal spray Flonase to use two sprays each nostril twice a day but she did stop this for testing today, although she did not need to do so. It does seem to help when she uses her nasal spray but does not take it away completely. She had a CT scan of her sinus about 10 years ago. She does not use any other medications.

She denies any frequent ear infections, dizziness, lightheadedness, or hearing impairment. She does have some eustachian tube dysfunction causing popping and clinging.

She does have some eye itching, tearing, dryness, and eyelid irritation. She states her eyelid irritation really is bothersome and is very itchy and she has been told that it is dermatitis. She does have a history of psoriasis as well mostly on her legs and may be associated with that. She states that it may be very itchy and irritating and can cause some eyelid swelling as well. This occurs a lot of the time.

She denies any history of wheezing or lung problems. She has not had a chest x-ray in the last five years. She has never had any allergic skin problems. She did have a previous allergy evaluation done so she has never been evaluated for allergies before.

ASSESSMENT:
1. Laryngopharyngeal reflux disease.
2. Blepharitis.
3. History of psoriasis.
4. Chronic postnasal drip.
5. Mixed allergic rhinitis.
6. History of chronic rhinosinusitis infection.

PLAN:
1. At this time, I do not think that allergies are the sole cause of patient troubles and I do think it may be a mix of her chronic postnasal drip due to a mixed or a nonallergic rhinitis as well as a possible laryngopharyngeal reflux disease. I would like to start Zantac 150 mg twice daily to continue keep her off the omeprazole, but see if we can get this under control better with the medication.
2. I also want to start a Dymista nasal spray one spray each nostril twice daily to see if this will help with the postnasal drip and be better suited for her rather than the Flonase.
3. I also talked with her that she may be exhibiting a blepharitis or a possible allergic contact dermatitis versus psoriasis. She has been worked up for possible allergic contact dermatitis in the past and has not changed any cosmetics or nail polishes and it does not seem to flare. I gave her a worksheet on how to treat blepharitis with warm compressors and cleansing of her eyelids and also gave her a prescription of hydrocortisone ointment 2.5% to apply to the eyelids if that is very itchy to help resolve the dermatitis present.
4. We will follow up in two weeks if these treatments are helping .

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