HISTORY: The patient is here for followup of seasonal perennial allergic rhinitis, on immunotherapy. She also has a history of tree nut allergy with primarily oropharyngeal symptoms and contact dermatitis to jewelry. She is followed by Dr. John Doe and last saw him on MM/DD/YYYY for seasonal perennial allergic rhinitis.
The patient has been receiving immunotherapy since MM/DD/YYYY and last received an injection today with birch/oak/maple/grass 10,000 PNU 0.55 mL, ragweed/mugwort 10,000 PNU 1 mL, cat/dog 2500 DAU 0.5 mL and mite and mold mix 10,000 units at 0.7 mL.
She received injections every two weeks and has not had any trouble with systemic reactions. She does get local reactions with some local swelling, which subsides within 24 hours. She does take Zyrtec prior to injections and regularly takes it every day.
In the past 1 to 2 months, she has had increased allergy symptoms, primarily with a sinus headache and some sinus pressure. Occasionally, she gets some itchy eyes; she cannot seem to tolerate allergy eye drops. She had been using Flonase initially but not recently. She denies rhinitis or congestion.
During the spring season, she has had her windows open and just recently turned the air conditioner on. She also moved to a new apartment in January, which has wall-to-wall carpeting. She does have dust covers on the pillow and mattress. She has no pets at home. She is not a smoker and does not live with any smokers.
She avoids tree nuts, which is the cause of oropharyngeal symptoms. She has an EpiPen but has not had to use it.
She has had no surgeries or hospitalizations since her last visit. She did have an episode of a sinus infection either in January or February.
She tells me with some kinds of jewelry, she gets hives.
MEDICATIONS: NuvaRing and Zyrtec.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: The patient is a healthy-appearing, well-nourished, well-developed (XX)-year-old girl, in no acute distress. Height is 5 feet 7 inches. Weight 138 pounds. Blood pressure is 98/62. Tympanic membranes are normal. Nose: Mildly pale and edematous. Throat is clear. Neck is supple without adenopathy. Lungs are clear. Heart: Regular rate and rhythm without murmur. Skin is clear.
IMPRESSION:
1. Seasonal perennial allergic rhinitis with recent flare-up to the tree pollen season.
2. Tree nut allergy with primarily oropharyngeal symptoms.
3. Contact dermatitis to jewelry, likely from nickel.
RECOMMENDATIONS:
1. Patch testing will be applied today and read in 48 hours.
2. Contact dermatitis, likely from nickel.
3. Use Zyrtec-D 12 Hour 1 tablet every 12 hours for increased allergy symptoms. Otherwise, she should take the Zyrtec 10 mg daily all year.
4. Add fluticasone 2 sprays per nostril daily.
5. Environmental control measures: Next spring, she should keep her windows closed and air conditioner on.
6. Continue with immunotherapy.
7. Follow up with Dr. John Doe in 1 year.
8. Continue avoidance of tree nuts.
9. EpiPen as needed.
