Patient comes in for a recheck for her allergy immunotherapy. She has been on the immunotherapy since February 2015. She does feel that it is significantly improving her allergy symptoms and she did have some overall fatigue and large local reactions to the injections when we were titrating up the 1:20 vial. So, we discontinued increasing her dose. She currently is at the 0.1 mL of 1:20 vial as a maintenance dose and she will need a refill shortly. She does feel that the immunotherapy is working. Now that she is not increasing the dose she does not have these associated feelings of fatigue, pain, headaches, or overall malaise and would like to pursue the immunotherapy. She does not have any troubles as far as locals anymore. She has slight irritation at the injection site but uses antihistamines as needed to help reduce this. She does use QNASL one spray each nostril twice daily for her constant nasal congestion. It has been getting better but she does feel that she needs medication intervention as well. She states that she has narrow nasal passageways and it is just may be something she might need to do regularly for quite some time. She also has some reflux disease that she uses lansoprazole to help with this. Otherwise, she is doing quite well. She would like to continue with the allergy immunotherapy. We can extend her frequency to every two to four weeks when she reaches her maintenance dose again on the new vial and she can contact us if she has any other troubles.

1. Allergic rhinitis.
2. Allergic conjunctivitis.
3. Mild intermittent asthma.
4. GERD.
5. Hypothyroidism.
6. History of large local reaction and fatigue with allergy immunotherapy.

1. At this time, we will continue with the allergy immunotherapy. We will stay at the 0.1 mL of 1:20 vial every four weeks. She was told that she can increase her frequency every two weeks if needed for reduction of allergy symptoms during the pollen season.
2. She will continue with QNASL 80 mcg once spray each nostril twice daily and she can also use antihistamines prior to the injections or as needed for allergy symptoms.
3. If she would like to pursue increasing her dose again, she will let us know although we are more than happy to continue at this dosage and see how the season goes for her.
4. She will follow up for vial refills or as needed.


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