Allergic rhinitis with dog

Patient is 77-year-old woman, who comes today due to problems with cough that has been worsening. She has various complications causing cough including GERD, vasomotor rhinitis, pulmonary fibrosis, asthma, and COPD. Currently, she complains of nasal symptoms including sneezing, postnasal drip, clear nasal drainage, occasional nose blowing, mouth breathing, yellow-green discharge and snoring and heartburn. This occurs year around. She has never thought she was an allergic person and has never had problems with seasonal allergies. She has no history of sinus infection, nasal polyps, TMJ, aspirin-induced nasal symptoms, frequent bad cold, or frequent tonsillitis. She does get frequent headaches and had nasal surgery in 1962. She did get relief at that time, I believe, with septoplasty. She currently takes Azelastine nasal spray which seems to help very well.

She denies any previous ear infection, dizziness, lightheadedness, or hearing impairment.

She denies eye symptoms including itching, redness, tearing, dryness, or burning.

She complains of mild-to-moderate wheezing and was diagnosed with asthma approximately five years ago. She takes Advair 250 daily to help with this. She also limits her exercise and play. She also has albuterol inhaler that she does not use very often.

She tries to use it when her cough is still bad at night to see if they help and she is unsure if they help. She also admits to frequent coughing spells, recurrent night cough, coughing up mucus. Yellow discharge seems to be worsening in the last a two weeks, shortness of breath with exercise, coughing on exertion, wheezing, laughing, lying down or talking on the phone.
She denies any allergic skin problem and has history of eczema atopic dermatitis. She has been evaluated for allergies in the past at least 35 years ago and she is also on the shots for a short time, was unsure if they helped or not. Her cough is due to postnasal drip. She sees a pulmonologist on a regular basis and has recent spirometry test performed and they have not any pulmonary fibrosis or other lung complaints that may be causing her cough.

ASSESSMENT:
1. Allergic rhinitis with dog.
2. Postnasal drip.
3. Upper airway cough syndrome.
4. Asthma, mild but moderate persistent.
5. Heartburn.
6. Hypertension.

PLAN:
1. At this time, we will prescribe QVAR through the nose using a baby bottle nipple tap to administer into the nose one puff twice daily each nostril to see if she gets better relief with this medication.
2. Continue with Advair 250/50 mg one puff daily for asthma symptoms.
3. Continue albuterol as needed.
4. We discussed lifestyle modifications and start reducing dog dander in her area including moving the dog from her sleeping area and keeping the house clean.
5. We will followup in two weeks’ time to determine the QVAR nasally is helping her symptoms at all and so the workup has to be reevaluated by her differential diagnosis including uncontrolled GERD, asthma, and COPD.

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