[Speaker A]: Hi. I'm fine. How are you?

[Speaker B]: Good. I'm Dr. Malam. Nice to meet you.

[Speaker A]: Nice to meet you as well. I'm Srajan.

[Speaker B]: Nice to meet you, Srajan. How can I help you today?

[Speaker A]: Yeah, I sent over some reports. I don't know if you have access to them, but you can probably look at them while I talk to you. I'll go over a brief history of all my symptoms.

[Speaker B]: Yeah, tell me. I guess the main symptoms, which are here to see me. That way I can kind of.

[Speaker A]: It's acid reflux, basically.

[Speaker B]: The conversation. Oh, it's like you're having, like, heartburn.

[Speaker A]: Yeah, it's heartburn.

[Speaker B]: Like, kind of like burning back here.

[Speaker A]: Burning sensations throughout my esophagus. That's what it feels like.

[Speaker B]: Okay.

[Speaker A]: When it gets serious, I often get, like, reflux up to my. Like in my mouth. Almost in my mouth, back of my throat, basically. But yeah, like, I moved to the US about three years ago, and that's about when this started.

[Speaker B]: Okay.

[Speaker A]: And at that time, I was just managing it with tums. I just thought, it's like I'm not eating properly or, like, just not timing my meals well. And that's probably why it's happening.

[Speaker B]: Yeah.

[Speaker A]: But it was until about, like, May of 2022. It was. That's how I was managing it. But it got really bad around that time in May 2022. May, June 2022. Sorry, May. June 2023. That is also around the time I was laid off. So it was a high stress, like, time for me. And. And the symptoms got really worse. I also had, like, some dysphagia and, like, a glow sensation for some time, which is when I visited the doctor. The doctor suggested I do an endoscopy. We got an endoscopy done, and I've sent you the biopsy results. Everything, like, physically looked normal. The biopsy also showed, like, borderline threshold eosinophilic count of 15, which might suggest, like, EOE. And then the doctor prescribed omeprazole to me, and he said, like, if it's eoe, we have to go on the six food elimination diet, and you have to get multiple biopsies done. And then because of the omeprazole, I was feeling better. And then, like, I essentially stopped following up. Okay. Around the same time, like, a week after I started the omeprazole, I got a really bad allergic reaction, like, hives all over my body. And I suspected it was the omeprazole. And I went back to the doctor and he basically switched me to femotirin, 10 milligrams daily, which I've been having for, like, almost three years now. And, like, passively managing, like, I go 24 hours, I start feeling the heartburn symptoms. I take the fermoterine, I feel fine. I've been doing that for, like, three years now. I had that allergy attack again, like, about three weeks ago. About a month ago. Same symptoms. Like, lots of highs all over my body. I had to take prednisolone to get those symptoms back in control. And now I'm still on Zyrtec once a day.

[Speaker B]: And what did your doctor think caused that allergic reaction?

[Speaker A]: We don't know. He also doesn't have enough data.

[Speaker B]: Did they send you to see an allergist to figure out what caused that?

[Speaker A]: No, not at the time. But after the second. Second attack, second, like, reaction, I went to the allergist. They said, like, I mean, it's hard to identify what it could be. I went into the angle of, like, if. If my acid ref, like, acidity symptoms are EOE related, can the food allergy causing the EOE also have caused this reaction? She seemed to be not so inclined to believe that. She still thinks it's separate. And that's why she suggested I also visit a gastroenterologist. Yeah, this is why I'm here.

[Speaker B]: Yeah.

[Speaker A]: And she also thinks that, like, since. Since, like, the second allergic reaction happened without the omeprazole. It probably wasn't the omeprazole. I initially believed it was the omeprazole because that's the only thing that I changed in, like, my lifestyle right around then.

[Speaker B]: But the second time you had the allergic reaction, you were not on omeprazole.

[Speaker A]: I wasn't.

[Speaker B]: So that one can't be attributed. But then when was the last time you had the allergic reaction?

[Speaker A]: It was May of 2023.

[Speaker B]: The second time you had the allergic reaction?

[Speaker A]: The second time was, like, a month ago. So mid Feb. Okay, I'll turn 35.

[Speaker B]: And you had. You had a rash the second time. The first time you had a rash. Right.

[Speaker A]: Both times it was hives all over my body.

[Speaker B]: Okay.

[Speaker A]: Yeah. Including my face.

[Speaker B]: Got it. And the second time as well?

[Speaker A]: Yep.

[Speaker B]: Okay.

[Speaker A]: And both times I had to take prednisolone to get the hives back under control, along with, like, Allegra and Zertek. And this time it feels like it lasted for a bit longer. Like, I still feel, like, tingling sensations under my skin, often at night, I guess coincides with the histamine cycle. But it's under control with some Zolotech at the moment.

[Speaker B]: Okay, but the allergist did some tests for you.

[Speaker A]: Yeah. So the first test she got me to do was a blood allergy test. That was actually my PCP, not my allergist.

[Speaker B]: And who is your allergist?

[Speaker A]: It's Dr. Sir. Sarah Silverman.

[Speaker B]: Okay.

[Speaker A]: Yeah.

[Speaker B]: Okay. And. But did they come up with anything with the testing that was done with the allergist?

[Speaker A]: The. The blood allergy report is attached. Has.

[Speaker B]: The blood allergy report is not as specific, though. So I presume the allergist did additional tests right afterwards, After. When you saw them, they did some type of testing for you?

[Speaker A]: Not yet.

[Speaker B]: Oh, so you're getting evaluated.

[Speaker A]: Yeah.

[Speaker B]: Okay, so we'll. Let's see what they think, I guess, because they haven't really evaluated. Do you haven't done any testing with allergist yet?

[Speaker A]: No.

[Speaker B]: You just saw them in clinic and they said, let's do something else.

[Speaker A]: I've done the blood allergy test, but that was recommended by my pcp and like, yeah, I know that a lot of it gives a lot of, like, false positives a lot of the times.

[Speaker B]: Yeah, yeah. It's not exactly, like, gonna rule it in. So.

[Speaker A]: Yeah. So what the allergist has prescribed me right now is to get like another blood test, but to check for, like, any kind of chronic signs of this hives being chronic in nature, like a trip taste test, a chronic urtic area test, stuff like that. The results for that are still to come in.

[Speaker B]: Okay, got it. So it's underway. So I think we'll see what they come up with. And then.

[Speaker A]: Yeah, this is like a general blood report.

[Speaker B]: Yeah, I see. So. So, yeah, So, I mean, I agree. I think that, you know, we don't really consider, per the most recent guidelines for EoE evaluation that came out last year, we don't really consider like a PPI responsive esophageal eosinophilia to be a true diagnosis. So. But, you know, in order to diagnose eosinophilical self identity, we also want to get biopsies. Not just in the lower part of the cell, physics, also higher up, it's either mid or upper esophagus, which wasn't done at the time of your last endoscopy. So I do think that, you know, we should repeat the endoscopy to get the proper biopsies and see where we are. Also, were you on omeprazole the time of the endoscopy? No, you were not on it yet. Okay. And you're not taking anything. You are or you are taking the 10 milligrams right now.

[Speaker A]: Yep.

[Speaker B]: Okay. So. Yeah. And are you having any more difficulties following or. That went away. Okay. But you're still feeling the heartburn every day?

[Speaker A]: Yeah, it only occurs like, once a day when I forget to take the formotidin and that's when I remember to take it. Yeah.

[Speaker B]: Okay, got it. But, yeah, I think, you know, with those esnfields there, we definitely want to kind of evaluate that further because we don't really. We've kind of changed the kind of algorithm for evaluating ESNFields there and like this last year, actually. So I would say that we should take a look just to figure out what's going on. And I'm glad that you're getting the allergy evaluation done because, you know, we want to know, you know, like, what were. What's causing these reactions, which obviously it's unclear what caused the hives last time.

[Speaker A]: But do you think it could be, like, related? Like, the food allergy is a common cause of ue and I have no idea.

[Speaker B]: I mean, you can be allergic to anything, so I really don't have any way to know. That would really be the allergist purview to help determine what caused that allergic reaction for you because there's so many different things that can cause allergic, as you can imagine.

[Speaker A]: Yeah.

[Speaker B]: And you can have multiple allergies to things as well that aren't even food allergies necessarily. And it sounds like you don't remember eating anything particular before that happened. Right.

[Speaker A]: Yeah, it wasn't. Yeah, Nothing specific. The only thing I remember before, like, the acute symptoms showed up was having a milk stout, and I suspect it could have been like the dairy plus, like alcohol being a co factor in causing the allergy, but that's my best guess.

[Speaker B]: Got it. Got it. Yeah. So definitely, like, you know, the allergist will evaluate for that. But I agree we should kind of. I would say my concern would be for eosinophilic esophagitis, but again, the. I think the. The testing was not complete for that. So we should kind of check because, like, you know, the management would be different. I would say, I notice you should continue the. For monitoring for now if you're taking that, if you're finding it helpful. But we should kind of take a look. You know, I think before. Or, I mean, you know, before we kind of consider. Obviously, I don't want to give you another proton pump inhibitor. Yeah. You know, because if you Had a possible allergic reaction. And definitely we'll follow up the allergy evaluation if you send us those records, you know, whenever that the testing is done.

[Speaker A]: Okay, of course.

[Speaker B]: And then, I mean, sure. Can they happen together? Of course. But is that what caused that reaction? I'm not sure. Right. So. But yeah, I think we should take a look to sort this out for you. My next availability for endoscopy. So I do procedures on Mondays at the moment. My next available date. I'm not in endoscopy next week. Unfortunately, I have availability on April 7th. Does that day work for you? Monday, April 7th.

[Speaker A]: Sure. Would you be doing the endoscopy?

[Speaker B]: Yes, I would be doing that.

[Speaker A]: And where would it be?

[Speaker B]: We do them at our endoscopy center, which is located on 26 street and Lexington Avenue.

[Speaker A]: Okay, cool. Can I take like a day or two to decide?

[Speaker B]: Of course, of course. I mean, I would recommend it though, because, you know, it would be good to know what's. What's going on so we can really properly treat it.

[Speaker A]: Yeah, that's what the answer is.

[Speaker B]: And that wouldn't really be able to be done without, I think, getting a proper diagnosis, which we don't have at this time, you know, so. And if you had an allergic reaction to one of the main treatments for the this condition, it would be good to know if that's actually going on. You know what I mean?

[Speaker A]: And what would the procedure entail? Like, would it be very similar to what I had done?

[Speaker B]: It is the same endoscopy procedure. It's done with anesthesia called monitored anesthesia care, which is just through the iv. It's quick on, quick off. You're breathing on your own the whole time. So it's not as deep of anesthesia that you get for surgery. Okay. And then here, once you sleep, we just have that thin, long, flexible tube with a camera at the end and then pass down the mouth, take a look and, you know, get some repeat biopsies and so on for you. It takes about, you know, 10, 15 minutes to the procedure. It's a low risk test. Very small risk of bleeding or infection, Very small risk of possible tear. We're always very careful, of course. And you're ready to go home at half an hour after the procedure is over. Just need someone to accompany home as a precaution because of the anesthesia and you can go back to work the following morning.

[Speaker A]: Okay, perfect. Okay. I think we can book around.

[Speaker B]: Yeah, I think we need to kind of get a better answer for you so we Know what we're treating so we can get you on the proper treatments. Because, I mean, you know, if this is eosinophilic esophageitis, the monitoring is not the proper treatment for that. And there's, you know, the majority of patients who have EOE that go untreated, the majority will develop complications over their lifetime, like narrowing strictures. You can get basically like a lot of scar tissue all throughout the esophagus, which can become a big problem. So, you know, I think we need to kind of figure out what's going on.

[Speaker A]: Okay.

[Speaker B]: You know. Yeah.

[Speaker A]: And then would you also mention, like, we didn't take biopsies from the upper esophagus last time, so would you be taking like.

[Speaker B]: Absolutely. Yeah, absolutely. We would be doing that to make sure we get you the proper diagnosis. 100. That would be like our focus. And of course we look for other things, but that will be the focus for why we're doing this. So definitely do that. So.

[Speaker A]: Okay, sounds good.

[Speaker B]: Okay.

[Speaker A]: April 7th sounds good to me.

[Speaker B]: Great. Yeah, I think maybe the sooner the better. I mean, if it doesn't work, I have very availability the next week too. But on the 7th I have 8, 7:00am, 8:30am, 10:00am oh, den works. Okay, great. That's a good time. Not too early, not too late. And then you can eat. So. Yeah, afterwards, which I know you already had the procedure and I'm sorry that it wasn't diagnostic, but, you know, what are you gonna do? We'll get you the answers you need in short order, I think, and just make sure everything's okay. But yeah, the famotidine, no issues should continue and you know, it's not gonna contribute to. It's not going to affect the results of the, the endoscopy, so.

[Speaker A]: Okay.

[Speaker B]: Whereas like omeprazone, those types of medications, but you're not on that medication.

[Speaker A]: Yeah. So I continue my promoter until the surgery.

[Speaker B]: Yeah. If you're finding it helpful, you can continue it, I think. You know, and sometimes it actually plays a role in like allergic type conditions as well.

[Speaker A]: Yeah. Because it's a nice histamine blocker.

[Speaker B]: Yeah, exactly. So so sometimes we'll use that for other things. So. Okay. Yeah. So sort this out. And when are you following up with your allergist?

[Speaker A]: As soon as I get my like, test results back for like the chronic stuff.

[Speaker B]: Okay.

[Speaker A]: Yeah, that should be this week.

[Speaker B]: Yeah. So let me give you our. I think you already sent the records over, but whenever those get done, if you can, to send them over to.

[Speaker A]: Oh yeah, I did. Yeah. Okay.

[Speaker B]: You already have it. Okay. You're on top of it. You're on top of it. I saw your software engineer. Where do you work?

[Speaker A]: I work at Rippling. It's like a. So it's a software for like payroll and HR products at the enterprise level.

[Speaker B]: Come on. Here. Pretty cool.

[Speaker A]: I work at like 4 volt rate central.

[Speaker B]: Oh, not too far. Yeah. We also do video visits by the way, for follow up appointments if that's more community.

[Speaker A]: Yeah, probably if you know, if you're working or busy. Sounds good.

[Speaker B]: Just FYI.

[Speaker A]: Yeah.

[Speaker B]: So what we'll try to do is, you know, my assistant will come in so they can set up the endoscopy. She'll give you our hand up with all the instructions you have to guide you. Okay. And all the address and everything per. And it will find you the endoscopy that day and of course I'll chat with you that day before you go home. Biops can take up to two weeks to come back. We'll plan a follow up with clinic around two weeks after or you know, video and that way we can tie all together. And I think the allergy evaluation will be getting done in the meantime as well. That will provide the information we need and then, you know, we'll just figure out what to do next. So. Yeah, if you don't have a history that you know of of like eczema or like, do you have like seasonal allergies?

[Speaker A]: No.

[Speaker B]: Okay.

[Speaker A]: Yeah, these two allergy reactions were like really out of the blue. Have never had an allergic reaction before.

[Speaker B]: Yeah, I, it's. Yeah, hopefully you know, I'm doing the. Right now and thankfully or not, you never had like get stuff or anything like that, right?

[Speaker A]: Yeah, like a brief like, like couple of days of this failure and it was pretty serious. But that's when I went through like. Yeah, I mean the gastric.

[Speaker B]: Yeah. And how frequently are you having heartburn right now?

[Speaker A]: It happens like once a day if I don't take my tumor.

[Speaker B]: Okay.

[Speaker A]: And it's like a feeling of heartburn. It's not very severe. It just feels uncomfortable.

[Speaker B]: Yeah, I understand.

[Speaker A]: I would say very slightly. Like that feeling of heartburn is accompanied with like slight regurgitation.

[Speaker B]: Okay.

[Speaker A]: But yeah.

[Speaker B]: And do you feel like any hoarseness or chronic cough or anything like that?

[Speaker A]: Yeah, I get cough if, if, if like I feel like there's regurgitation happening. I do cough because of that.

[Speaker B]: Got it, got it. Okay.

[Speaker A]: Yeah, it's, it's, it's, it's minor and it's rare.

[Speaker B]: I understand.

[Speaker A]: Yeah.

[Speaker B]: Okay. So I'll get it sorted out for you.

[Speaker A]: Okay, perfect.

[Speaker B]: Yeah, I'm. I'm just going to do a quick exam. Just want to have care. Hold. Examine your neck. Okay. Okay. And speaking of life, you're not having abdominal pain, right? No, not really. Okay. You're okay. Actually, sorry, my hands are so cold. I don't want to shock your skin. Okay. All right. Okay, great. Okay, so you can go ahead. You can go ahead and come back over to the chair, and I'll just have my assistant come in, we'll get you set up for the procedure. Okay.

[Speaker A]: Okay.

[Speaker B]: And I know you've had it before, so it should be pretty easy. And we'll sort this out for you. And, you know, thanks for coming in. I'm glad that, you know, you're looking into it.

[Speaker A]: Yeah.

[Speaker B]: You kind of easy.

[Speaker A]: Yeah, it's been. I should have followed up, like, much earlier, but, you know.

[Speaker B]: Okay. I mean, you're here now and life is busy.

[Speaker A]: Right.

[Speaker B]: So it's still pretty early, I would say. It's not like you visit like 15 years, because I think that's more like when things can.

[Speaker A]: Yeah.

[Speaker B]: You know, if there's active inflammation, we can treat it. Right. It's when scar tissue develops there when they. You know, after the inflammation has been going on for a long time, they can be harder to treat. So I think we should still be okay.

[Speaker A]: Yeah, that's very. Sounds optimistic. Yeah.

[Speaker B]: Yeah. Probably know the natural history of eosinophilic esophageitis, which this very well may be based on the ace nipples there. But. But let's see.

[Speaker A]: Yeah.

[Speaker B]: Okay.

[Speaker A]: Yeah.

[Speaker B]: Okay.

[Speaker A]: Should I just wait here?

[Speaker B]: Just wait here. Should we write in, look at the paperwork and go over any questions related to the procedure day, and I'll plan to see you then. Okay.

[Speaker A]: Okay. Thank you as well.

[Speaker B]: Have a great day.

[Speaker A]: You do. Bye. Bye.

[Speaker B]: It.

