Allergy Consult Letter Template - Adult

Thank you for your kind referral of Taylor, seen May-13-2025 in the Allergy Clinic. I was grateful to have the helpful referral note.

IMPRESSION AND PLAN:
1. Contact dermatitis, unspecified (L30.9):
   - Recommend a patch test to identify potential allergens in personal care products, including fragrances and preservatives.
   - Advise the patient to avoid further steroid injections until after the patch test to prevent masking of results.
   - Continue using topical steroids as prescribed, with assistance from the patient’s spouse for application.
   - Schedule the patch test for the next available Monday when the patient is not traveling.
   - Follow up two days after the patch test application to review results and determine further management.

Thank you for involving me in his care.

HISTORY OF PRESENT ILLNESS:
The patient is an 82-year-old male presenting with skin irritation and rash that began approximately six months ago. Initially, the rash involved the scalp and arms but has since improved significantly, with some irritation persisting on the back. The patient changed laundry detergents from a generic brand to 'All Free and Clear,' which has led to some improvement. There have been no recent changes in other personal care products, no use of dryer sheets or whitening pods, and no unusual supplements taken. The patient denies any recent travel or exposure to unusual environments. There is no history of eczema or other skin conditions during childhood. The patient has received two steroid injections, the last one being two weeks ago, which coincided with a marked improvement in symptoms. The scalp irritation has resolved, and the erythema and papulation on the arms have significantly healed. The patient denies any use of cosmetics or hair dye. There are no signs of scabies or similar conditions. The patient’s son, who resides with him, has also experienced similar symptoms, raising the possibility of a shared environmental factor.

PAST MEDICAL HISTORY:
- History of skin irritation and rash that began approximately six months ago.
- No history of eczema or other skin conditions during childhood.

SURGICAL HISTORY:
No history of past surgeries.

ALLERGY HISTORY:
No history of asthma, eczema, recurrent urticaria, IgE mediated food allergies, systemic insect sting allergy.

CURRENT MEDICATIONS:
- Plavix (clopidogrel)
- Aspirin
- Cholesterol medications
- Blood pressure medications

DRUG ALLERGIES:
NKDA

FAMILY HISTORY:
The patient’s son, who resides with him, has experienced similar symptoms. However, there is no shared travel or exposure to unusual environments between the patient and his son.

SOCIAL HISTORY/ENVIRONMENTAL HISTORY:
- Work: 
- Smoking: 
- Etoh: 
- Marijuana: 
- Home: The patient resides with his son.
- Heating: 
- Carpet: 
- Pets: 
- Extended benefits: 

EXAMINATION:
The patient appeared well-nourished and in no acute distress. Dermatological examination revealed erythema and papulation on the inner arms, symmetric and significantly healed. Scattered papulation with areas of redness was noted on the upper back. The scalp was clear with no active irritation. Tibial discoloration and dryness on the lower extremities were consistent with age-related changes. There were no signs of scabies or other parasitic conditions.

INVESTIGATIONS:
No investigations were performed during this visit. A patch test has been recommended to identify potential allergens in personal care products.

Morgan Ellis, MD  
Regional Medical Center