Fatigue

Patient comes in for a recheck. I last saw him on February 16, 2016. At that time we started hydroxyzine 25 mg. He has been taking this three times daily. The first week he started with this went very well. He did not have any hives although symptoms did return a week after. He was currently on Allegra two to three times per day prior to this and still having outbreaks. We did pursue lab work at last visit and everything was normal including CBC, CMP, ESR, CRP, thyroid antibodies, TSH, and free T4 as well as ANA. Although, he was currently having fever and feeling sick with a cold. He did have elevated lymphocytes and slightly elevated CRP. I do believe this was due to an acute vital infection. Everything else is normal. He is still getting hives however and he is very anxious about this and it seems to occur at school. It happened twice this last week. He does feel like it is better but he is still concerned that it is not resolving. He does feel that hydroxyzine helps him sleep although mother states that that it seems that he is fatigued even though he feels that hydroxyzine is not causing drowsiness. Mother states that he does not seem like he is acting like himself. He was wondering if he could try out Allegra again during the day to see if this would help and do hydroxyzine in the evening. I think that would be a good choice to see if we can find the best treatment for him and see if we can continue to alleviate his hives reaction. We did discuss possibility of Xolair being the next step if we cannot get these resolved.

ASSESSMENT:
1. Cholinergic urticaria.
2. Pityriasis sicca.
3. Fatigue.
4. Depression.

PLAN:
1. At this time, we will continue to try resolving his urticaria with antihistamines. I encouraged him to try taking two Allegra in the morning and then hydroxyzine in the evening to see if this helps. I also add Singulair 10 mg daily as well to see if this provides anymore relief either.
2. We did discuss opportunity of using Xolair. This may be the next step for patient to see if this helps resolve his cholinergic urticaria.
3. We will follow up in one month to see have this is going. If he continues to have outbreaks, we may pursue Xolair or more blood work to further rule out anything else going on.

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