Halitosis

Patient is 37-year-old female who has had increasing complains of breathing troubles including clearing of throat and coughing as well as hoarseness. She also is having complaints of itching and hives that occurred recently and as well as concern for food allergies. She was diagnosed with bronchitis and pneumonia infection a few months ago that significantly impaired her health. She states that beginning of October she got two doses of antibiotics for this as well as dose of prednisone and things resolved somewhat, but she still continues to have some symptoms of trouble breathing and coughing. After that time of bronchitis, she did also have outbreak of hives that lasted for three days and then resolved and has now recurred. This is very itchy and she showed me pictures of this hives at the time. She is also concerned about food allergies as she has had problems tolerating wheat as well as dairy and is continuing to have more problems with other foods and wanting to be tested for allergies today.

She currently complains of nasal symptoms including sneezing, postnasal drip, nasal stuffiness, frequent throat clearing, hoarseness, frequent nose bleeds, belching a lot and heartburn. She states that she recently just started having these complaints in September 2015. She does admit to having sinus infections in the past as well as frequent headaches. She denies any nasal polyps, aspirin-induced nasal symptoms, nasal surgery, frequent tonsillitis. She states that these symptoms are very severe. She saw doctor two times in a week, struggled through the week for several weeks but she has been back to work. She has tried Zyrtec, albuterol inhaler, Benadryl, cough syrup with codeine, DayQuil, Nyquil, prednisone, antibiotics, lansoprazole, nasal rinses, and Mucinex for all of her complaints with moderate to very little symptom relief. She denies any frequent ear infection. She also denies any eye itching, redness, tearing, dryness, burning, light hurting her eyes, yellow discharge from eyes, eyelid swelling, or irritation.

She has recently been having some mild-to-moderate wheezing episodes and problems with not being able to exercise due to her lung function. She states that this is possibly due to bronchitis and she is also diagnosed with pneumonia when this onset occurred. She did get ProAir inhaler that she has been using. She used for the first two weeks after this infection and feels like she has not needed in last two to three months. She did required steroids in October 2015 for this. She admits to frequent coughing spells, recurrent night cough, coughing up mucus, coughing and wheezing, coughing lying down and coughing with talking on the phone. She denies any allergic skin problem and she has never been evaluated for allergies before.

ASSESSMENT:
1. Allergic rhinitis.
2. Concern for food allergy.
3. Possible cough-variant asthma.
4. Possible GERD.
5. History of acute bronchitis infection and pneumonia.
6. Halitosis.

PLAN:
1. At this time, I think we can assume that she does have significant allergies to seasonal environment and reducing the allergen load she receives may help with resolve her symptoms. I will begin on Flonase two sprays each nostril twice daily to try for the next two weeks.
2. I also gave her albuterol inhaler and encouraged her that this may be cough-variant asthma so to use albuterol one to two puffs as needed when her coughing increases or throat clearing increases.
3. I also prescribed her chlorhexidine gluconate oral rinse to try for the next week gargling for 30 seconds twice daily to help with her halitosis that her husband is complaining about and she really wants to get resolved. Also, I encouraged her that this could be due to her nasal passageway and mucus collection, so ideally Flonase will help with this as well.
4. We will follow up in two weeks time to see if these interventions will help some of her complaints.
5. I also discussed with her that the foods positive today were most likely false positive since she tolerates these foods without severe allergic reaction. Although, we did discuss that she can remove these items from her diet and slowly introduce one at a time after two weeks to see if she has increasing stomach complaints. I also gave her worksheet on FODMAP diet to encourage her to try this as well to help relieve some of her stomach complaints. She will also follow up with a dietitian and gastroenterologist to further pursue her stomach pain.

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