General Allergy Consult

Introduction

Dear Dr. [Referring Doctor's Last Name], I had the pleasure of seeing [Patient's First Name], a [Patient's Age]-year-old [Patient's Gender] at the allergy clinic. [He/She/They] was referred for an allergy assessment in the setting of [Chief Complaint].

History of Presenting Illness

[Provide a detailed narrative of the patient's presenting illness, including onset, duration, symptoms, triggers, treatments tried, and any relevant medical history related to the current complaint.]

Allergy Review

[insert the following text: The patient has no prior history of asthma, eczema, medication allergies, venom allergies, or IgE-mediated food allergies]

Past Medical History

[List the patient's past medical conditions and past surgical history.] (list the past medical history and number them on separate lines) For example: 1. [Condition 1] 2. [Condition 2] ... [n. Condition n]

Current Medications

[Insert medications and dosage if available. List them on separate lines and number them.]

Birth History

[Provide details about the patient's birth, including term and any complications if applicable, if the patient is a child.]

Medication Allergies

[List any known medication allergies or state 'NKDA' if none.]

Immunizations

[State the status of the patient's immunizations, whether they are up to date or if any are pending, if the patient is a child.]

Social History

[Provide details about the patient's social history, including smoking, alcohol use, occupation, schooling and any relevant lifestyle factors. Provide details of parents' occupation if the patient is a child. Provide details about extended health benefits.] For example: [Patient First Name] does not smoke or drink alcohol. [He/She/They] works as a [Occupation].

Environmental History

[Describe the patient's living environment, including details about the home, heating, presence of pets, and any other relevant environmental factors.] For example: [Patient First Name] lives in a [description of home]. There is [description of heating and any environmental factors].

Family History

[Detail any relevant family medical history, particularly related to allergies, atopy or respiratory conditions.]

Physical Exam

BP: [insert BP], HR: [Insert HR] BPM [Insert the following text without editing it: [insert patient's name] appears well. Head and neck examination was normal. Cardiac exam revealed a normal S1 and S2. Chest examination is clear with no wheezes or crackles. Skin examination did not reveal active eczema patches or urticaria lesions. The rest of the examination is unremarkable.

Investigations

Skin Test Results

[Insert the following text: Environmental Allergens: Positive skin test to dust mites, cat, dog, tree pollens, grass pollen, molds and weeds. Negative skin testing to dust mites, cat, dog, tree pollens, grass pollen, molds and weeds. Both histamine and saline control are appropriate.]

Impression

[Provide a concise clinical impression based on the assessment.] For example: 1. [Diagnosis]

Plan

[Outline the management plan, including any treatments, medications, investigations and lifestyle modifications.] For example: 1. [Treatment or recommendation] 2. [Medication and dosage]

Follow-up

[Specify the follow-up timeline and any specific instructions for future appointments.] For example: Follow-up: [Timeframe]

Closure

I appreciate the opportunity to participate in [Patient First Name]'s care, and I hope my suggestions are helpful. If any questions arise please feel free to contact my office.