Esophagitis

Patient is 21-year-old man how is having many complaints of severe abdominal pain and the diarrhea that has been going on for most of his life although has been progressively worse in the last two years. He states that he also has this associated with muscle aches and headaches as well as vomiting episodes especially after eating dairy products. He has removed gluten from his diet approximately two years ago and that seems to be helping his fatigue and muscle aches. He also has removed dairy from his diet six or seven months ago as well and that seems to be helping with the vomiting episodes. He has been evaluated by the gastroenterologist who referred him to us to rule out any food allergies. At the time of evaluation he was not specifically diagnosed for celiac disease since he has been off of gluten for two years’ time and if he would like to pursue a diagnosis he would have to resume wheat diet or diet with wheat for at least six weeks’ time. They did do an endoscopy and colonoscopy at the time of evaluation and he was shown to have some esophagitis and was given antifungal medication as well as Prilosec 20 mg daily for esophagitis. He does state that the antifungal seems to help and Prilosec feels like it might be causing some relief of his symptoms, although he is still having severe abdominal cramping constantly.

He denies any history of seasonal allergies or any problems with nasal congestion, mouth breathing or snoring. He does admit to heartburn. He denies any frequent sinus infection, nasal polyps, aspirin-induced nasal symptoms, nasal surgery, frequent bad cold or frequent tonsillitis. He denies any frequent ear infection, dizziness, lightheadedness, hearing impairment. He also denies any eye symptoms of itching, redness, burning, eyelid irritation or swelling.

He denies any wheezing or lung problems and has never had to use an albuterol or nebulizer treatments. He has not had chest x-rays in the last five years. He does not have any eczema or problems of skin, although he does feel that he gets rashes occasionally but is not sure if this is eczema or not. He currently does not have any problems with skin. He has never been evaluated for allergies before.

ASSESSMENT:
1. Esophagitis.
2. Possible celiac disease.
3. Concern for food allergies.
4. Irritable bowel syndrome with diarrhea.
5. Depression and anxiety.

PLAN:
1. At this time, we can rule out food allergies contributing to his stomach complaints. We will let his gastroenterologist know that the results today were negative.
2. I encouraged him to continue working with the gastroenterologist to further identify what may be contributing to his severe stomach pain and diarrhea. I encouraged him to continue using Prilosec 20 mg daily. He will continue to not have dairy or wheat in his diet if that seems to help his symptoms. Although, if he wants to pursue celiac disease testing, he would have to reintroduce wheat to his diet.
3. We discussed briefly about FODMAP diet to see if this would further control his symptoms. He seems to be quite frustrated today with not having any answers unfortunately, although testing shows there is no food allergies at present. We will see him back as needed.

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