Allergy Consult Letter - Over 18 years

Thank you for your kind referral of Clara, seen on May 19, 2025, in the Allergy Clinic. I was grateful to have the helpful referral note.

Patient Chief Complaint:  
Clara, a 19-year-old female, presented with concerns regarding skin reactions at insulin pump insertion sites, management of allergic rhinitis, and eczema.

Problem List:  
1. Insulin Pump Site Reactions: Clara has been using an insulin pump for the past 18 months for type 1 diabetes management. She reports developing small, skin-colored bumps with red centers at the pump insertion sites, which worsen with prolonged use. She denies any current infections or worsening of her eczema. She has a history of sensitive skin and eczema, which may contribute to these reactions.  
2. Allergic Rhinitis: Clara experiences persistent allergic rhinitis symptoms, including frequent sinus infections (approximately three times per month), swollen cheeks, frontal headaches, yellow nasal discharge, puffy eyes, and runny, watery eyes. She has a known allergy to cats and dust mites, confirmed by environmental allergy testing. She uses Avamys nasal spray daily, which provides some relief but does not fully control her symptoms. She lives with two cats, one of which exacerbates her symptoms.  
3. Eczema: Clara has a history of eczema, which is generally well-controlled with topical treatment during flare-ups. She reports sensitive skin and reactions to many moisturizers, which limits her use of such products. She bathes every two days but does not use moisturizers regularly.  
4. Respiratory Symptoms: Clara reports occasional chest tightness and coughing, particularly during sinus infections or exposure to irritants. Pulmonary function testing performed during this visit showed no significant changes post-bronchodilator, ruling out asthma as a current diagnosis.

Allergy Review:  
Clara has confirmed allergies to cat dander and dust mites. She denies any food allergies, adverse reactions to medications, or significant reactions to mosquito or blackfly bites beyond swelling. She has no history of bee or wasp stings. There is no history of anaphylactic reactions. She underwent allergy testing in childhood, which confirmed environmental allergies.

Past Medical History:  
1. Type 1 Diabetes: Diagnosed at age 13, initially presenting with symptoms of appendicitis and later confirmed with diabetic ketoacidosis requiring hospitalization.  
2. Eczema: Generally well-controlled with topical treatment during flare-ups.  
3. Allergic Rhinitis: Characterized by frequent sinus infections.  

Immunizations:  
The patient is uncertain.  

Past Surgical History:  
None.  

Current Medications:  
1. Novorapid insulin via insulin pump.  
2. Avamys nasal spray, daily.  
3. Topical cream for eczema, as needed during flare-ups.  
4. Cetirizine, as needed for allergic reactions.  
5. Concerta for ADHD management.  

Adverse Reactions to Medications:  
No adverse reactions to medications indicated.  

Family History:  
- Mother: Significant allergies.  
- Brother: Childhood asthma.  
- Maternal grandmother: Chronic sinus issues, uses a CPAP machine.  

Environmental History:  
- Residence: House.  
- History of water damage or mold: No.  
- Carpeting: Yes, in the bedroom.  
- Pets: Two cats, one of which exacerbates symptoms.  
- Heating type: Not specified.  
- Bedding wash frequency: Every one to two weeks.  
- Smoking in the home: No.  

Social History:  
- Patient is a non-smoker.  
- Patient is a full-time journalism student.  
- Patient has extended medical benefits.  

Review of Systems:  
- No nausea, vomiting, or difficulty breathing.  
- No exercise-induced breathing problems.  
- No snoring or reflux symptoms.  
- No food getting stuck in the throat.  

Physical Examination:  
- Clara appears alert, interactive, and cooperative.  
- Normal oropharynx and bilateral nares.  
- Cardiovascular examination reveals normal S1 and S2 heart sounds without murmurs.  
- Respiratory examination shows good air entry bilaterally without adventitious sounds or increased work of breathing.  
- Dermatological examination shows small, skin-colored bumps with a red center at two insulin pump insertion sites on the lower abdomen.  

Investigations:  
- Pulmonary function test results show an FEV1/FVC ratio of 0.91 pre-bronchodilator and 0.99 post-bronchodilator, with an FEV1 of 94% predicted in both cases, indicating no significant change with bronchodilator use.  
- Allergy testing confirms positive reactions to cat dander and dust mites, with negative results for other allergens including cockroach, trees, grass, ragweed, and mold.  

Impression and Plan:  
1. Allergic Rhinitis:  
Impression: Persistent allergic rhinitis symptoms with confirmed allergies to cats and dust mites.  
Plan:  
- Discontinued Avamys nasal spray and prescribed Ryaltris nasal spray, with instructions for proper administration and dosing.  
- Discussed immunotherapy options for cat and dust mite allergies, including allergy shots and sublingual immunotherapy.  
- Recommended environmental control measures, including washing bed linens every one to two weeks, using air filtration systems, and considering dust mite covers for bedding.  

2. Eczema:  
Impression: Well-controlled eczema with a history of sensitive skin and reactions to moisturizers.  
Plan:  
- Advised daily bathing or showering with immediate application of a non-reactive moisturizer, such as Vaseline or Glaxal Base, to maintain skin hydration and barrier function.  

3. Insulin Pump Site Reactions:  
Impression: Likely due to sensitive skin and history of eczema.  
Plan:  
- Referred Clara to Dr. Morgan, an allergist, for evaluation and potential patch testing to identify specific irritants or allergens contributing to site reactions.  
- Advised continued monitoring of pump sites for signs of infection or worsening reactions.  

4. Respiratory Symptoms:  
Impression: Occasional chest tightness and coughing, likely irritant-induced.  
Plan:  
- Provided a sample of Symbicort inhaler for use during episodes of chest tightness.  
- Advised avoiding known triggers, such as concrete dust.  

Follow Up:  
Clara will follow up with Dr. Morgan for patch testing and further evaluation of skin reactions. She was advised to contact the clinic if symptoms worsen or if she experiences any adverse reactions to the new medications. No routine follow-up scheduled at this time; Clara may return as needed for ongoing management of her conditions.  

Dr. Daniel Carter  
Regional Medical Center