Recent bacterial infection and exposure to viral infection

Patient is 37-year-old female who comes in due to a new onset of swelling. She states that this happened Tuesday morning at about 4 o’clock in the morning. She woke up and her throat was swollen particularly on the outside of her throat and a muscle tissue. Her pharynx was swollen and when she looked in her mouth her uvula was two to three times the size it usually is. This naturally scared her, so she went to the emergency room. They did give her epinephrine at that time and IV Benadryl and prednisone. This was the day after 07/04/2016. She has had a lot of family in town. They did do a lot of fireworks and barbecue, but she has been not encountering anything that she has never been around. She has not eaten anything that she has never eaten before. These are all just basic things that she has always had. She did handle a lot of the fireworks, but has done this before and is not sure of what may have triggered this event. She does state that her 4-year-old has been sick lately. She did go to the doctor for him and they diagnosed him with a virus and he has had a rash associated with this typical viral exanthem and she is not sure if she has gotten exposed to this or not, but feels fine. She was sick about four weeks ago, went to the urgent care for a bad cough and fever and she was diagnosed with pneumonia; however, they did not do a chest x-ray and was given azithromycin for five days and an inhaler. This resolved after one week and she felt perfectly fine after that. The swelling is continuing after she gets back from the ER. Things were better and she was discharged with prednisone dose 60 mg for the next four days. She then went to Seattle for a family trip on Wednesday and was doing fine until Thursday she started having swelling again and decided she needed to get home, so she came back to come see me today on Friday. She is currently having some swelling. It is fairly mild. She took the last dose of prednisone today of 60 mg. She woke up this morning a little swollen in the face. She also has had skin flushing and redness around her face and chest associated with it. She is concerned that she is out of prednisone now and she worries that this may revert back and will need to go to the ER. She has been taking Benadryl. They recommended her doing so every four to six hours. She has not done it that often, but may be about two to three times per day when she remembers.

She denies any history of seasonal allergies, sneezing, clear nasal discharge, or nasal stuffiness. She has never had problems with this before. She denies frequent infections driven by tonsillitis. She does get tonsillitis occasionally due to one of her kids. She denies history of nasal polyps, TMJ, aspirin-induced nasal symptoms, and nasal surgery. She takes ibuprofen as needed for headaches and thinks that does help. She is not taking any ibuprofen recently.

She denies frequent ear infection, dizziness, lightheadedness, or hearing impairment.

She does have some eye redness, tearing, dryness, and burning associated with this. She was diagnosed with uveitis about three years ago.

She denies a history of wheezing or asthma symptoms. She has not had any airway problems. She denies any airway compromising since she has had the swelling or wheezing associated with this. She denies frequent coughing spells and shortness of breath with exercise.

She denies any allergic skin problems. She has never had any eczema or urticaria before. She has never been evaluated for allergies before and never had problems with allergies before.

ASSESSMENT:
1. Acute idiopathic angioedema with urticaria.
2. Snoring and possible sleep apnea.
3. Recent bacterial infection and exposure to viral infection.

PLAN:
1. At this time, I talked with and it is very hard to determine exactly why she is triggered with angioedema attack. I did discuss that it is due to a viral exposure possibly from her son and this is one of the most common triggers of this. She did not take any ACE-inhibitors or other current medications. She also has not been taking ibuprofen or other NSAID-class medication since this has begun.
2. I do think she may need some more prednisone at this time because she continues to have swelling, so I will give her 20 mg prednisone to take every eight hours until swelling resolves. I do want to also get her on high dose of antihistamines. She will start with two tablets of Zyrtec twice daily to three times daily. I also prescribed her hydroxyzine 25 mg to take at night as she is having troubles with swelling and we can also increase that dose to every four hours as needed.
3. I did give her an EpiPen just in case she needs it and if she does use it she is told to go to the emergency room to get evaluated. It is the weekend, so I did encourage her to call me if she has any concerns or troubles to try to help her stay out of the emergency room. I am hoping that this will resolve with this treatment and we should hopefully get her off the prednisone. We will follow up with patient in two weeks.

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