Assignment task: A 25-year old male presents to your office complaining of a 3-month history of runny nose, itchy eyes, and exertional cough and wheezing. These symptoms have been progressively worsening. His past medical history is significant for seasonal allergies. His family history is significant only for hypertension in his parents. His siblings and children are in good health. His social history is negative for smoking. He has worked as an animal laboratory technician for the last 6 months. On questioning, his symptoms initially were worse toward the end of the work week but are now continuous. He has been taking over- the-counter antihistamines, which helped initially but no longer do. On review of systems, he has noted hives that are less now that he has been taking the antihistamines on a regular basis. On examination, his BMI is 23, blood pressure is 120/75 mm HG, pulse is 72 beats/min, and respiratory rate is 18 breaths/min. His conjunctiva are hyperemic and nasal turbinates boggy. The lung examination reveals prolonged inspiratory-to-expiratory ratio and end expiratory wheezing. The heart examination is normal and there is no edema.
- What is the most likely diagnosis?
- What further evaluation should be considered?
- What are the initial steps in therapy?