Gluten intolerance

Patient is 24-year-old female who approximately over the last six months she has had increasing gastrointestinal complaints including stomach pain, constipation, irritable bowel syndrome, anxiety, restlessness, headache, and bloating. She states that it seems to be triggered by certain foods. She has continued on gluten tolerance. She does not eat gluten products now due to this. She does have flare-ups of acne as well that seems to be associated with her increasing abdominal complaints. She is concerned about food allergies particularly and would like to be tested today for these.

She does state that she does have some seasonal allergies as well including nasal symptoms, nasal stuffiness, postnasal drip, clear nasal discharge during the spring, fall and summer season. She also complains mostly of eye symptoms of itching, redness, tearing, dryness, and burning. She denies light hurting her eyes, yellow discharge from eyes, eyelid swelling, or irritation. She denies any history of sinus infection, nasal polyp, frequent bad cold, frequent tonsillitis, or frequent ear infection.

She denies any lung problems or wheezing.

She does state she has some eczema particularly with winter. She does have a 2.5% hydrocortisone ointment that she uses on her hands as needed for flares of eczema and she gets good control with this. She has never been evaluated for allergies before.

ASSESSMENT:
1. Irritable bowel syndrome.
2. Allergic rhinitis.
3. Allergic conjunctivitis.
4. Concern for food allergies.
5. Gluten intolerance.

PLAN:
1. At this time, we discussed with patient that unfortunately there are no specific food allergies that have been determined today that may be contributing to her symptoms. We did discuss that with IgE-mediated test we mostly look for severe allergy directly related to ingestion of certain foods every time that you ingest them within five to 30 minutes causing itching, hives all over the body, swelling, anaphylaxis.
2. I did give her some information on FODMAP diet as well hypoallergenic diet. She has tried multiple elimination diets in the past but she would like to try again with these tips of diet to reduce all inflammatory foods and allergenic foods from the diet and slowly reintroduce one thing at a time to see if she can get the best diet plan for her to reduce her symptoms overall.
3. She has seen a gastroenterologist for her troubles and does have the gluten intolerance. She may proceed to test for celiac disease if necessary in the future if she would like to reintroduce eating gluten in her diet and pursue that.
4. We will have her come back next week for seasonal allergy testing. She would like to pursue immunotherapy if she has a lot of significant reactions to allergens particularly to the pet danders as well as she does currently take Zyrtec year round for her troubles.

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