Allergy Consult letter - 18 years and under

Thank you for your kind referral of Olivia, seen on 2025-06-13 in the Allergy Clinic. I was grateful to have the helpful referral note.  
Olivia was accompanied to today’s visit by her mother.  

Patient Chief Complaint:  
Olivia, a four-and-a-half-year-old female with a history of prematurity and asthma, presents with recurrent wheezing and respiratory symptoms. Her symptoms include frequent illnesses characterized by runny nose, wheezing, and coughing, which tend to worsen at night.  

Problem List:  
1. Recurrent wheezing and respiratory symptoms: Olivia was born at 27 weeks gestation and required a three-month hospitalization post-birth. During the pregnancy, her mother received two rounds of steroids to aid in lung development. She has been hospitalized four to five times for respiratory issues and has been treated with prednisolone once. She has also been on antibiotics approximately three times. Her symptoms are managed with budesonide for daily use and albuterol as needed, though adherence to the regimen is inconsistent due to caregiver circumstances. She has not seen a pulmonologist or other specialists recently.  

Allergy Review:  
- No specific allergic conditions or symptoms were reported.  
- No known reactions to mosquito bites.  
- Olivia does not have an epi-pen.  
- She has not seen an allergist before.  

Past Medical History:  
- Obstetrical history: During pregnancy, the mother received two rounds of steroids to aid in lung development.  
- Birth details:  
  - Born premature at 27 weeks gestation.  
  - Delivery type: Not specified.  
  - Birth status: Required a three-month hospitalization post-birth.  
  - Birth weight: Not specified.  
  - Newborn health: Required hospitalization for lung development.  
- History of prematurity and asthma.  

Immunizations:  
Immunizations are up to date.  

Past Surgical History:  
None.  

Current Medications:  
1. Budesonide daily.  
2. Albuterol as needed.  

Adverse Reactions to Medications:  
No known drug allergies (NKDA).  

Developmental History:  
Olivia has met her early developmental milestones appropriately. No parental concerns regarding vision or hearing were noted. She is currently in Pre-K.  

Family History:  
- No history of allergies or immunodeficiency in the family.  

Environmental History:  
- Number of households: Not specified.  
- Residence: No known mold, flooding, or water damage in the home.  
- Carpeting: Not specified.  
- Pets: No pets at home.  
- Heating type: Not specified.  
- Bedding wash frequency: Not specified.  
- Smoking in the home: No.  

Social History:  
- Patient lives with her mother and other caregivers.  
- Mother works nights, which impacts medication adherence.  
- Patient does not have extended health benefits.  

Review of Systems:  
- Constitutional: No fever, weight loss, or fatigue.  
- Eyes: No vision changes or eye pain.  
- ENT: No hearing loss, nasal congestion, or sore throat.  
- Cardiovascular: No chest pain or palpitations.  
- Respiratory: No shortness of breath or cough.  
- Gastrointestinal: No nausea, vomiting, or diarrhea.  
- Genitourinary: No dysuria or hematuria.  
- Musculoskeletal: No joint pain or swelling.  
- Skin: No rashes or itching.  
- Neurological: No headaches or dizziness.  

Physical Examination:  
- Lungs are clear to auscultation bilaterally.  
- Oral pharynx is clear.  
- Olivia appears well-nourished and in no acute distress.  
- Rhinologic examination reveals cloudy mucus and some swelling.  
- No evidence of polyps or turbinate hypertrophy is noted.  
- Cardio-respiratory examination reveals clear lung sounds without wheezing or crackles.  
- Dermatological examination shows no signs of eczema or hives.  

Investigations:  
No investigations were performed during this visit.  

Impression and Plan:  
1. Recurrent wheezing and respiratory symptoms in a child with a history of prematurity and asthma: Allergy testing is planned, and Olivia is to be off Xyzal for five days prior to testing. Continue current medications as prescribed.  

Follow Up:  
I recommend following up with the pediatrician as needed.  

Sincerely,  
David Harper, MD  
Regional Medical Center for Asthma and Allergy