Multiple sclerosis

Patient is 60-year-old man who recently moved here two years ago. He admits that his allergy symptoms seemed to be increasing since he has moved to the Boise area. He complains of nasal symptoms including postnasal drip, sore throat, hoarseness, snoring and heartburn. These symptoms seem to be worse in May, June, July and September and October.

He denies any problems with frequent sinus infection, nasal polyps, frequent headaches, and aspirin-induced nasal symptoms, frequent bad colds and frequently tonsillitis. He did have a nasal surgery performed in 1994 from a crush trauma to his nose from a car accident. He states that his nasal symptoms are mild. He has used aspirin and Zyrtec in the past for this with very little relief.

He also denies any frequent ear infections, dizziness, lightheadedness or hearing impairment.

He does admit to some eye symptoms of itching, redness, tearing, dryness, burning, and yellow discharge coming from eyes, eyelid swelling, and eyelid irritation which occurs some of the time.

He denies any history of wheezing or lung problems and has not needed any inhalers in the past.

He denies any allergic skin problems such as eczema or atopic dermatitis currently or in the past.

He has been evaluated for allergies when he was approximately 58 years old by Dr.

ASSESSMENT:
1. Allergic conjunctivitis.
2. Allergic rhinitis.
3. Multiple sclerosis.
4. Heartburn, well controlled.

PLAN:
1. At this time, we will begin QNASL one spray each nostril twice daily to see if this can reduce some of his allergic rhinitis and conjunctivitis symptoms.
2. Although he is not allergic to many things, he does have significant allergy to animal hair, dust mite and molds. So, we further discussed lifestyle modifications on how to provide an adequate defense when visiting family friends who own cats and dogs and utilize a Zyrtec medication and nasal sprays prior to being exposed to his allergens. We could also talk about allergy immunotherapy as a long-term management if he fails to have adequate relief with prescription medications.
3. He will call in 10 days to let us know how the QNASL is working to better relief his symptoms.

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