Pruritus

Patient is 18-year-old female who comes because of hives said it is just not going away. She states that this has been occurring for the last three months. She has been given a dose of prednisone and also been using a Benadryl, Claritin, and topical corticosteroids like hydrocortisone ointment and nothing really seem to resolve the hives completely. She has been to four different urgent care clinics and to her primary care Dr. to help treat these hives. She did not have anything like this before and does not recall changing anything in her environment including detergent, soaps, or cosmetic products. She does not usually typically have seasonal allergy symptoms, troubles with allergic rhinitis or conjunctivitis. She also does not feel that she was sick at all this year or had any type of viral or bacterial infection. It is not associated with joint pains, lymphadenopathy, fevers, or any weight loss. She is not sure why she all of a sudden has developed these hives currently.

She denies any history of nasal symptoms of sneezing, clear nasal discharge, nasal stuffiness, or mouth breathing. She does not have any seasonal variation to nasal symptoms. She has had occasional sinus infections. She did have frequent tonsillitis, but her tonsils are out now. She denies nasal polyps, TMJ, frequent headaches, aspirin induced nasal symptoms, or nasal surgery. She does not use any medications for any allergy symptoms or nasal sprays.

She denies ear infections, dizziness, lightheadedness, or hearing impairment.

She denies eye itching, redness, tearing, dryness, burning, light hurting her eyes, yellow discharge from eyes, eyelid swelling, or eyelid irritation. This occurs never.

She did have some eczema about two years ago on the arms. She has not been evaluated for allergies before.

ASSESSMENT:
1. Chronic idiopathic urticaria unresponsive to antihistamines.
2. Pruritus.
3. History of eczema.

PLAN:
1. At this time, I do want to see if we can try adding higher doses and different types of antihistamines at this time as this has not been tried. I will have her to use Zyrtec three times per day and hydroxyzine 20 mg at night as needed. I also want to give her Singulair in the evening as well to see if this can in fact control her hives.
2. If this does not help then we may consider starting Xolair. I also want to do some lab work. She does have a family history of rheumatoid arthritis. She is not complaining of any joint pains, but just to be on the safe side we will do some blood work. I will have her do free T4, TSH, antithyroid antibodies, ANA, CMP, CRP, ESR, RS, CBC with differential. We will follow up in one month to see how she is doing.

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