Allergy and Immunology Consultation

Chief Complaint

Allergy and Immunology Consultation

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Thank you for your referral of [name] for Allergy and Immunology Consultation. [pronoun] was examined on [date]. PAST MEDICAL HISTORY: 1. Eosinophilic esophagitis (EOE). 2. Anaphylactic reaction. CURRENT MEDICATIONS: 1. [drug_name] [dosage] for allergies. 2. Nasal spray. ALLERGIES: [name] has confirmed food allergies to peanuts, tree nuts, and kiwis, which cause anaphylactic reactions. [pronoun] has environmental allergies to dust mites, tree pollen, and grass pollen. [pronoun] does not have known drug allergies. FAMILY HISTORY: - Mother: Environmental allergies. - Father: Environmental allergies and bronchial asthma. - Sister: Environmental allergies, food hypersensitivity, and bronchial asthma. There is no family history of immunodeficiency or autoimmunity. SOCIAL HISTORY: - Occupation: Works in golf course maintenance. - Smoking Status: Non-smoker with no smokers in the home. - Home Environment: Lives in a [age]-year-old house with no carpeting and has air conditioning. - Pets: Has a dog. - Drug Coverage: Not specified. HISTORY: [name] has been experiencing severe allergies since [date], characterized by post-nasal drip, a cough that has since subsided, and nasal congestion primarily at night. Symptoms are less pronounced during the day. [pronoun] denies frequent sneezing, reports that [pronoun] sense of smell is intact, and does not experience facial pain or pressure. [pronoun] also denies itchy, watery eyes unless in contact with horses or certain dog breeds like huskies. [name] has been using a nasal spray, which initially caused a nosebleed, leading [pronoun] to temporarily discontinue its use. [pronoun] resumed the spray without further issues. [pronoun] has a dog at home, which [pronoun] has had for [number] years, and works in golf course maintenance, which may expose [pronoun] to allergens such as grass and dust mites. [pronoun] experienced an anaphylactic reaction in [date], which required hospitalization and coincided with the worsening of [pronoun] allergy symptoms. PHYSICAL EXAMS: - Pharynx: Clear. - Nasal: Significant obstruction, especially on the left side. - Pulmonary: Unremarkable with normal respiratory sounds. INVESTIGATIONS: Skin testing reveals positive reactions to dog, cat, dust mites, tree pollen, and grass pollen, with a significant reaction to birch tree pollen. IMPRESSION 1. Allergic rhinitis OPINION AND RECOMMENDATIONS: 1. Allergic Rhinitis: - Continued use of the nasal spray with proper technique to minimize side effects. - Consideration of allergy shots for dog, cat, tree, and grass allergens, starting with weekly injections and transitioning to monthly maintenance. - Education on the proper use of nasal spray to avoid nosebleeds. - Discussion of the potential benefits and risks of immunotherapy, including the low risk of anaphylaxis. - Scheduled follow-up to monitor response to treatment and adjust the plan as necessary. I will see [name] again in a few weeks for [pronoun] first allergy shot in person. Thank you for involving me in this patient's care. Please do not hesitate to contact me if you have any further questions or concerns.