Allergy Assessment Report

Chief Complaint

Allergy Assessment Report

specialty

Allergy and Immunology

tags

Template

Thank-you for your referral of this [age] old [gender] for assessment of allergies on [date]. Patient was accompanied in clinic today by [relation] [relation]. Summary:I want the summary to be brief with diagnosis and a few salient points in numbered form. Can include prescriptions, investigations and follow-up if relevant. If no prescriptions, can indicate that no changes were made to management. More details can be included in the impression and plan section 1. [Condition] - include the diagnosis and results of testing. if the testing is not relevant to the condition, please state so. (eg : Acute urticaria - testing positive to grass, not likely relevant) 2. Prescriptions: [medication] 3. Investigations: Include any future investigations required (example, any bloodwork requisitions provided) 4. Follow-up: what treatment is required Findings: what was the outcome of testing? If negative for environmental testing, state "testing negative to common inhalant allergens", include food results on a separate, numbered line, if negative for food, state testing negative to foods of concern. If positive, state sensitizations present to foods that tested positive. Impression/Suggestions: 1. Include the first issue here - include explanation of diagnosis - recommended interventions -prescriptions, state no prescriptions provided if none provided - other treatment discussions - investigations (if any) - follow-up 2. Second Issue - include explanation of diagnosis - recommended interventions -prescriptions - other treatment discussions - investigations (if any) - follow-up 3. Can include other issues separately numbered 3,4,5,6 etc as required. Follow-up: If no follow-up, state: "No follow-up arranged at this time". Other options I use depending on situation " Follow-up as required". If follow-up is recommended, state the recommended follow-up. Medical Profile: (this is the medical history prior to the encounter. I would like to include all medical conditions in list form including allergic conditions such as allergic rhinitis, asthma, atopic dermatitis or food allergy. If mild, can include mild in parentheses). This is a list form without added sentences. Example: 1. Asthma 2. Peanut Allergy 3. Hypertension Current Medications: a list of current medications. History of Presenting Illness: Do not include information regarding allergy test results in this section. Include a summary of the history and concerns reported by the patient. This includes descriptions of allergic reactions, anaphylaxis, etc. (include an allergic history with details regarding the following topics, each in separate paragraphs: Allergic Rhinitis/Sinusitis/Conjunctivitis: State the symptoms that the patient complains of. This includes nasal symptoms such as nasal congestion, either unilateral or bilateral, rhinorrhea and if so, clear or purulent, sneezing, facial pressure, headache, hyposmia or purulence. Eye symptoms such as itchy eyes, red eyes, tearing. Itchy mouth. Describe when the patient experiences these symptoms such as spring, summer, autumn. State whether or not the patient experiences symptoms associated with animal exposures. Describe which medications the patient has used to manage the symptoms and the response they have experienced, any side effects or other concerns about the medications Asthma: If there is no asthma, state that there is no diagnosis of asthma. If asthma, when were they diagnosed, what are their symptoms such as dyspnea, cough, wheeze, chest-tightness, shortness of breath. What are their triggers such as animal exposure, seasonal pollens, viral infections, cold exposures, etc. What medications do they take? How often do they take them? Is their asthma controlled? Have they had flares of asthma that required hospitalizations or systemic steroids? Food Allergy: If there is no history of food allergy, state that the patient does not report a history of food allergy. If there is a history of food allergy concerns, report food of concern separately. For foods of concern, state the time between ingestion and onset of symptoms, type of symptoms, which may include oral pruritus, dysphagia, hives, vomiting, respiratory symptoms, light-headedness or others. State if any medications were taken. State if an epipen was used and if so, what was the impact. Does the patient have a medic alert bracelet? Atopic Dermatitis: If there is no history of atopic dermatitis, state this. If there is atopic dermatitis, how do they describe the rash. Where on the body does it impact the patient. What are triggers for the eruptions. Do they apply moisturizer regularly? What medications do they use. Hives: If concerns about acute or chronic urticaria, can list it here. For hives please document description including if they are raised wheals, pruritic, if they come and go over hours, if there is associated angioedema. Mention if the symptoms improve with antihistamines. Mention any potential triggers. State whether or not the eruptions are associated with nsaid use, opiate use, stress or physically inducible triggers. Venom Reactions: If concerns about venom reactions, state it here. Mention nature of reaction, type of insect, response to medications and if they have required an epipen. Drug Allergy: If patient reports a history of drug allergy, report the type of drug taken, how many doses before onset of symptoms, mention whether or not any features of a systemic cutaneous reaction, systemic reaction or mucosal symptoms. Other health concerns: (list if any, otherwise include No other health concerns) Born at term ([duration]) via cesarean section. Uncomplicated pregnancy. No concerns regarding growth or developmental milestones. Vaccines up to date. (Include this for all patients under 6 years of age). If we do not discuss birth history, do not include information that we have not confirmed. Social History: What time of home do they live in? (assume detached home if not stated otherwise). Who do they live with? Are there pets in the home? Does the patient smoke? If the patient is working, what is their occupation? If an adult, state marital status if available. Are there smokers in the home? (if answer is no to any of the questions, state the negative) Family History: Any history of atopic disease in family members include here. Can also include other pertinent medical conditions discussed. Examination: Head and neck exam: no atopic stigmata Nasopharynx normal nasal mucosa Oropharynx: No thrush Lungs: Breath sounds heard to the bases bilaterally. No wheeze appreciated No crackles heard CV Exam: S1 and S2 Skin: clear, no urticaria and no eczema Remainder of exam unremarkable Allergy Testing: (Please summarize allergy testing as follows. If I state that environmental testing was done it usually always includes every section noted below. So if I perform environmental testing and do not state the result, assume negative. 1. Environmental testing Animal Dander: if negative, state negative to common animal dander. if there are positives, state which tests were positive. Example: positive to cat, dog horse. Mould Spores: similar to above, Dust Mite: if negative, state negative, if positive, state positive Grass Pollens: if negative, state negative, if positive, state positive Tree Pollens: if negative, state negative, if positive, state positive Weed Pollens: if negative, state negative, if positive, state positive) 2. Food Testing (if performed, summarize the results). Delete the food testing section if no foods are tested): 3. Venom Testing (if performed, summarize the results) Delete the venom testing section if no venoms are tested): (Do not include any diagnosis/recommendations after testing results. All of this should be included in the summary and impression/suggestions. Do not write any text after the testing results section. )