Pacheco Assessment & Plan

Assessment & Plan: 1. Problem Patient presents with a history of seasonal allergic rhinitis, exacerbated by recent exposure to ragweed pollen. Diagnosis: Allergic Rhinitis. Physical examination revealed mild nasal congestion and clear rhinorrhea. Lab results from a recent allergy panel showed elevated IgE levels specific to ragweed and dust mites. The patient's condition has worsened since the last visit, with increased sneezing and nasal congestion. Plan: - Patient will continue to use loratadine 10mg daily for symptom management. Advised to use a nasal saline rinse twice daily. Prescribed an albuterol inhaler for use as needed for any wheezing. - Referral to Dr. Emily Carter, a pulmonologist, for further evaluation of potential asthma triggers. - Follow-up appointment scheduled for 1 month from today, 1 December 2024, to assess symptom control and medication efficacy. - Patient was educated on allergen avoidance strategies, including keeping windows closed during peak pollen seasons and using air purifiers. Provided counselling on proper inhaler technique.