A&I New Patient

HPI: The patient, a 35-year-old female, presents with a main complaint of persistent nasal congestion and sneezing, which has been ongoing for the past three months. Symptoms are exacerbated during the spring season and are accompanied by itchy eyes and skin rashes. The patient reports using over-the-counter antihistamines with partial relief. Allergy History: The patient has a known allergy to peanuts, resulting in hives and difficulty breathing. She also reports a history of allergic reactions to bee stings. Environmental History: The patient works as a school teacher and lives in a suburban area with her husband and two cats. She does not smoke but is frequently exposed to secondhand smoke at her workplace. Current Medications: - Cetirizine 10 mg daily - Albuterol inhaler as needed Past Medical and Surgical History: - Asthma diagnosed at age 10 - Appendectomy at age 20 Physical Exam: - Nasal mucosa is swollen and pale - Skin examination reveals erythematous patches on the forearms Laboratory and Test Results: - Positive skin prick test for grass pollen and dust mites - Normal spirometry results Assessment and Plan: - Allergic rhinitis (ICD-10: J30.9) - Asthma (ICD-10: J45.909) - Continue current antihistamine therapy - Initiate intranasal corticosteroid spray - Recommend allergen avoidance strategies - Follow-up in 3 months for reassessment