General Allergy Consult Note, Complex Prompt

Chief Complaint

All

Introduction

Thank you for your kind referral of [patient first and last name], seen [date of appointment ( MMMM-DD-YYYY)] in the Allergy Clinic. I was grateful to have the helpful referral note. [If patient is under 18 years of age, include the following: [Patient first name] was accompanied to today's visit by [patient pronoun] [parent (parents first names)/father (fathers first name)/mother (mothers first name)/[caregiver(s), be specific about relation if possible](caregiver(s) first name(s))].] [Today’s appointment took place via telehealth [Medeo/doxy.me]. [The patient/Parents /Mother/Father/The parent/Caregiver(s)] [was/were] happy to proceed with use of this technology.]

Patient Chief Complaint

[Document the details surrounding the child’s chief complaint. Include onset, duration, frequency, severity, and any associated symptoms. Describe the parent’s account of the current issues they are having in relation to the chief complaint and any concerns or expectations they express.]

Problem List

For each problem, provide a very detailed narrative history including onset, duration, character, and associated symptoms, past investigations, and previous physicians seen or treatments tried. Include details, quotes, and examples. No new diagnosis should be made in this section, and it should not repeat information provided in the Impression and Plan section. If the problem is Asthma, include the following: - Symptoms including description, timing or seasonality, and whether they are worsening, stable, or improving over time. - Detailed description of triggers. - List recent exacerbations, hospitalizations including specific number of visits, date or dates of admission (in MMMM-DD-YYYY format), and medication administered during specific hospital visit. - Testing prior to current visit including results. - Relevant medications issued prior to current visit including doses, and medication administration compliance. - Impacts to quality of life including school or work. If the problem is Chronic Urticaria, include the following: - [Patient First Name] has had symptoms of urticaria [and angioedema] for the past [#] [weeks/months/years]. [He/She] had [active lesions today/pictures to review/a description] that [was/were] consistent with urticaria [and angioedema]. [He/She] develops active lesions [daily/every other day/a few times a week/once a week/a few times a month/once a month]. [Patient First Name] [denies/has experienced] symptoms of [fever/weight loss/arthralgias/arthritis/cold/heat sensitivity/abdominal pain/bone pain] recently. There were [no/some] features suggestive of urticarial vasculitis. [Patient First Name] [has/has not] noted physical triggers for their urticaria [including: [dermatographism/cold/heat/vibration/sun exposure/water/pressure]]. [He/She] has /not noted worsening hives with [alcohol/NSAIDs/stress]. [[Patient First Name] is concerned that food may be a trigger for their hives. [Patient First Name] has/has not tried treatment with [cetirizine/loratadine/desloratadine/bilastine/rupatadine/Benadryl/antihistamines] at [standard/doubled/quadrupled] dosing with [no/partial/good] response.] If the problem is Food Allergy, include the following: - Specific food. - Age of patient at time of reaction (age can be in months if provided). - Size of ingested serving, and specific food ingested. - Symptoms after ingestion, including symptom timing and duration. - Whether patient proceeded to hospital, and any additional symptoms during transport. - Symptoms upon arrival at the Emergency Department (ED). - Specific medicine(s) given, who it was given by, location where it was administered (home, hospital). - Symptoms that improved or resolved, including timing of improvement or resolve. - Whether symptoms have reoccurred. - Whether any specific testing was completed previously, including specific test results. - Any accidental or subsequent same food exposures since original; include the form of exposure and size of exposure. The specific allergenic food may be included as an ingredient in another food (e.g., egg in cookie dough). Include symptoms or lack of symptoms which may be a contraindication to the presence of continued allergy to this food or ingredient. - Any additional treatments prescribed previously (e.g., food ladder). - Whether patient has an epinephrine auto-injector, include brand, type, and whether they have training devices available. - Whether parents have done the training course at www.allergyware.ca. If Food Introduction: - What foods have been tried, what if any symptoms were present. - What foods have not been tried. If Eczema: - Age of onset (age can be in months if provided). - Whether it is mild. - How it is managed. - What exacerbates rashes if anything. - Whether medicated topicals are used. Output as a list of each problem with a detailed history in sentence format: 1. [Problem 1]: [detailed history] 2. [Problem 2]: [detailed history] If the problem is Food Allergy, separate each type of food further in a lettered sub-list under the Food Allergy numbered list item: 1. Food Allergy: a) [Specific food]: [detailed history]

Allergy Review

[detailed description of patient's reported other allergic conditions, such as reaction to medications, asthma, environmental allergies, hives, problems swallowing including food sticking or choking on food, eczema or dry, scaly and itchy rash, mouth itching or tingling with fresh fruit or vegetables, reactions to insect stings bite from honey bee or wasp or yellow jacker or hornet [include symptoms that presented including local swelling less than 10cm diameter, excessive swelling greater than 10cm diameter, hives, low blood pressure, breathing problems, constriction of airway, belly problems including nausea vomiting diarrhea or abdominal pain, and the time since last reaction to insect sting], large reaction, greater than 10 cm, to mosquito bite including time since last mosquito bite reaction. Avoid generalized terms like allergic reaction; instead use specific reported symptoms, and be specific around food or environmental triggers. This section should not include narrative surrounding tests or test results conducted at this appointment. This section should not duplicate items already contained within the Problem List, should not make new diagnosis, and should not duplicate information contained within the Impression and Plan section] [Include whether patient has an epi-pen] [Include whether the patient has seen an allergist before, when and who they are.] [Do not include parent or sibling allergies in this section]

Past Medical History

[if patient is under 18 years old, include: [obstetrical history, including any maternal health concerns which may include high blood pressure, diabetes, illness, medications, alcohol, drugs, smoking or other] [patient first name] was born [at term/premature/postdates] by [spontaneous vaginal delivery without assistance/assisted vaginal delivery (forceps)/assisted vaginal delivery (vacuum)/cesarean section (planned)/cesarean section (unplanned)] and [was vigorous at birth/required intervention at birth [described interventions immediately after birth that were required].] Birth weight was [birth weight in pounds and ounces]. [There were no health concerns during the newborn period/The newborn period was notable for [breathing, feeding, jaundice or other problems]] The patient's history is notable for the atopic conditions outlined above [as well as the following concerns:] [Do not duplicate information from the Problem List or Allergy Review Sections] [1. Past medical history problem 1] (numbered list in numerical order with each problem on a separate line) [2. Past medical history problem 2]

Immunizations

[Immunizations are up to date/The patient has not received any routine vaccinations (unimmunized)/Immunizations are incomplete/Caregiver is uncertain if routine immunizations have been received]

Past Surgical History

[List in numerical order]

Current Medications

1. [medication 1] [dosage] [frequency] 2. [medication 2] [dosage] [frequency]

Adverse Reactions to Medications

[There are no known allergies to medications./The patient reports the following adverse reactions with medications:] (group in a numerical list based on the medicine type) 1. [Penicillin based antibiotics] [Include medicine, describe the reaction and how long ago the reaction occurred] 2. [Non-steroidal anti-inflammatory medication including aspirin, naproxen or ibuprofen] [Include medicine, describe the reaction and how long ago the reaction occurred] 3. [Sulfa based antibiotics] [Include medicine, describe the reaction and how long ago the reaction occurred] 4. [Other] [Include medicine, describe the reaction and how long ago the reaction occurred] [If patient is over 18 years old include any contact allergies] 1. [Latex] [Describe the substance, the reaction, and how long ago the reaction occurred] 2. [Other] [Describe the substance, the reaction, and how long ago the reaction occurred]

Developmental History

[Only include if patient is under 18 years of age] [Development milestones delays or concerns, including concerns regarding vision or hearing] [Patient First Name] has/hasn't met [her/his/their] early developmental milestones appropriately. any parental concerns regarding vision or hearing. [Current grade in school, any school related problems, or problems with friends]

Family History

[Include significant medical conditions in first-degree relatives, e.g., diabetes, hypertension, heart disease, genetic disorders] -Parent/guardian 1, [parent 1 name [parent 1 age]: listed health concerns] -Parent/guardian 2, [parent 2 name [parent 2 age]: listed health concerns] -Sibling 1, [sibling 1 name [sibling 1 age]: listed health concerns] -Sibling 2, [Sibling 2 name [sibling 2 age]: listed health concerns]

Environmental History

[For children under 18 years of age, list how may households the child lives in and with who, This may include the child living in multiple households.] [[patient first name] name lives in [a/an] [condo/apartment/basement suite/house/townhouse/mobile home/other] that is [year] years old. There [is a/is no] history of water damage or mold. There [is/is no] carpeting in the home. [Pronoun] [has/have/does not have/do not have] [a/any/multiple] [cat/cats/dog/dogs/pets]. There is [forced air/radiant/baseboard/heat pump/gas fireplace/wood fireplace/other] heating. Bedding is washed [weekly/every 2 weeks/monthly]. There [is/is no] smoking in the home.]

Social History

[For patients 18 years of age and under please use the following: [patient first name] lives at home with [list of family member names in the home]. [Parent 1 name] works as a/an [Parent 1 occupation]. [Parent 2 name] works as a/an [Parent 2 occupation]. [patient first name] has/does not have access to extended health benefits.] [For patients over 18 years please use the following: [Patient first name] is [a smoker/a non-smoker]. [patient pronoun] [works/work/is retired] [as a/in] [job/field]. [Pronoun] [has/has/does not have/do not have] access to extended medical benefits.]

Review of Systems

Review of systems is non-contributory.

Physical Examination

[Weight: [weight in kg]] (do not include if data not available from transcript or note) [Estimated Weight: [weight in kg]] (can include if appointment is a telehealth consult and estimated weight is provided in transcript or note. Do not include both a weight and estimated weight.) [Height: [height in cm]] (do not include if data not available from transcript or note) [BMI: [BMI value]] (do not include if data not available from transcript or note) [For patients under 18 years of age, include weight-age and height-age percentiles] [Weight-age percentile: [weight age percentile value]] do not include if data not available from transcript or note) [Height-age percentile: [height-age percentile value]] (do not include if data not available from transcript or note) (List each of the above on its own line) (Summarize the following in sentence format in a single paragraph) [For patients under 18, indicate whether they are happy and well appearing] [Pupils are equal and reactive] [There is no conjunctivitis or congestion] [Anterior rhinoscopy is unremarkable/notable for mild turbinate hypertrophy bilaterally] (do not include if visit done via telehealth) [Tympanic membranes are normal/partially obscured by cerumen.](do not include if visit done via telehealth) [There are no polyps or ulcerations.](do not include if visit done via telehealth) [Nares are clear/There is clear rhinorrhea bilaterally]. (do not include if visit done via telehealth) The oropharynx is [healthy/notable for [details]. (do not include if visit done via telehealth) There [is no lymphadenopathy/are a few/numerous lymph nodes palpable in the anterior cervical chain]. (do not include if visit done via telehealth) Respiratory examination is [clear and there is no clubbing/is notable for[details].] (do not include if visit done via telehealth) Heart sounds: [are normal and peripheral pulses are palpable and equal. ] Abdominal examination: [ is unremarkable/notable for [details]]. (do not include if visit done via telehealth) Dermatological examination is [unremarkable./notable for [details]]. (do not include if visit done via telehealth) [There are / are no visible rashes] [Do not hallucinate; use only the transcript, contextual notes or clinical note as a reference for the information included in this section. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not include it in your output, just leave the relevant placeholder or section blank. If appointment was conducted by telehealth indicate Physical examination was limited by telehealth modality, and only describe results of visual examination explicitly noted in the transcript]

Investigations

[Skin prick testing was completed to [inhalant allergens]. Testing was negative to [list positive skin prick tests (list with comma "." delimiter)]. Testing was positive to [list positive skin prick tests (list with comma "." delimiter)]. Positive and negative controls were completed. (Do not include if skin prick testing was not completed at this visit) [Spirometry. [Technique was good./There were some limitations with technique, we did eventually meet ATS criteria]. Spirometry shows [mild obstruction with significant bronchodilator response (list percent increase in FEV1 after bronchodilator)] [Indicate improvement in FC after bronchodilator and improvement in the duration of expiratory phase if any]. Test [is/is not] compatible with a diagnosis of asthma.] (Do not include if spirometry was not completed at this visit) [Indicate whether tests have been completed recently prior to this appointment, and the results of these tests (ie. Serum IgE testing, skin prick testing, or spirometry)] [Do not hallucinate; use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank.]

Impression and Plan

[The impression should include a numerical list of problems identified; do not provide a detailed repeat of history. All listed problems need to be supported by findings in subjective and objective areas above. Include important positives & negatives that inform the differential diagnosis & identify most likely diagnoses. Take the assessment of the major problem to the highest level of diagnosis that you can, for example, “low back sprain caused by radiculitis involving left 5th LS nerve root.” Provide differential diagnoses for the major new problem. The plan is to include a specific diagnostic and specific treatment plan for each differential diagnosis. The diagnostic plan may include specific tests, procedures, other laboratory studies, consultations, etc. The treatment plan should include: a rational for their inclusion in the plan, patient education, pharmacotherapy if any, other therapeutic procedures. Document discussions of new medication or procedures including side effects, complications, & potential outcomes. Include patient education & any handouts provided] [If includes Eczema Eczema. [Patient First Name] has [mild/moderate/severe] eczema that currently impacts [flexural surfaces of the limbs/the face/the torso/the entire body]. I explained that eczema is caused by a mix of genetic and environmental factors. Eczema is not caused by food; however, having eczema places children at increased risk of developing life-threatening food allergy. Good control of eczema is an important aspect of food allergy prevention. I have recommended the following management plan: -Avoidance of detergent-based soap -Frequent application of emollient -[Hydrocortisone 2.5% in Aquaphor/Fluocinolone acetonide 0.01% oil] applied BID as emollient x 7-14 days when rash affects >50% BSA, and used PRN on face, axilla and groin areas -Hydrocortisone 2.5% [cream/ointment|in Aquaphor] BID PRN for rash on the face, axilla and groin -[Betamethasone valerate 0.1% ointment/Mometasone 0.1% ointment] used [OD/BID] PRN for rash on the body [-Mometasone 0.1% lotion applied BID to the scalp x 7-14 days and then PRN] [-Fucidin 2% ointment BID x 7-10 days with signs of infection] [-Occlusive therapy with wet wraps: application of medicated therapies, thick emollient, a damp layer of clean clothing, and a dry layer of clean clothing] [-Bleach baths 1-2/7 for the next 2-3 months – recipe provided] Topical steroid therapies should be applied BID until the affected area is flat and smooth, and then discontinued (if the steroid is appropriately dosed, this should happen within 1-2 weeks). I have asked [the patient/parents] to take interval photographs of the rash to assess response. ] [If includes Possible adverse reaction to medications Possible adverse reaction to medication. [Patient First Name] has a remote history of delayed rash following use of [penicillin/amoxicillin/cephalexin]. [She/He/They] [is/are] an excellent candidate for an oral challenge to see whether this label can be removed from their record. I’ll place [her/him/them] them on the list for an upcoming Drug clinic day. ] [If includes Anaphylaxis Anaphylaxis. [Patient First Name] has now had 2 episodes within the past year consistent with anaphylaxis. I have requested ED records to provide additional information. Based on the history, the reactions sound most in keeping with anaphylaxis (mast cell mediated). I have requested a baseline serum tryptase when well, and have provided a standing order for this (to be done within 2 hours of symptom onset with any subsequent episodes). After reviewing the ED records we can decide whether further evaluation (for alternative causes of similar symptoms) might be indicated. [Patient First Name] will return for skin prick testing to see whether an allergic cause can be identified. We did discuss today that not all anaphylaxis is caused by allergy (e.g. anaphylaxis can be the result of mast cell degranulation that is independent of IgE production). For now, [Patient First Name] will avoid [List things to avoid], and the epinephrine autoinjector must be available to [them/her/him] at all times. We reviewed the available autoinjector types, and [Patient First Name] has selected the [EpiPen/Allerject/Emerade]. I've sent through a prescription for this. We've reviewed technique and indications for use, and I've provided a written anaphylaxis emergency plan. ] [If includes Allergic rhinitis Allergic rhinitis ([grass pollen/tree pollen/weed pollen/dust mite/cat/dog/molds]). [Patient First Name] has a history of symptoms that include [rhinorrhea/congestion/sneezing/post-nasal drip/ocular pruritus]. Symptoms are [seasonal/perennial/with seasonal worsening/with worsening around furred animals] consistent with positive testing to [grass pollen/tree pollen/dust mite/cat/dog/molds/weed pollen]. Symptoms are currently [well managed/under-treated]. I have provided written information regarding avoidance measures. In particular, I have recommended [dust mite covers/more frequent washing of bedding/keeping animals out of the bedroom/keeping windows closed on days when pollen counts are highest]. Mild, intermittent symptoms can be managed with non-sedating antihistamines used as needed (cetirizine, loratadine, desloratadine, fexofenadine, rupatadine, bilastine). Persistent symptoms, particularly congestion, should be managed with a regular nasal steroid. I have prescribed [Avamys/Omnaris/Nasonex/Dymista] to be used [1/2] sprays per nostril [daily/BID]. The spray should be used for a minimum of 4-6 weeks for maximal effect. Patanol eye drops can be used for residual symptoms of pruritus. Saline nasal rinses may also be of benefit. Immunotherapy is an option for patients with symptoms refractory to pharmacotherapy. I have provided [Patient First Name] with written information about this today, and [she/he/they] can contact the office to proceed with this.] [If includes Asthma: Asthma, [poor control/no signs of poor control]. [patient name] meets criteria for asthma based on [reversible obstruction on spirometry/positive provocative challenge/ Canadian Paediatric Society & Canadian Thoracic Society criteria for the diagnosis of asthma in the preschool population]. There are [signs of poor control/no signs of poor control] on today's history. I [did not make any changes to management./made the following changes to management:[detail changes to management]] I have provided [parents/[parent first name]] with an asthma action plan. [Patient First Name/Parents] will contact a health care provider if [pronoun] [notice/notices] signs of poor control, including symptoms or reliever use >3/7, nocturnal symptoms, activity limitation, or if there is an exacerbation requiring health care presentation. I have recommended that [parents/[patient first name]] watch the following educational video released by the BCCH Asthma clinic: https://www.youtube.com/watch?v=GJms3kX8Eg0.] [If includes Cold urticaria Cold urticaria. [Patient First Name]’s history [and testing| ] are consistent with cold urticaria, a form of physical urticaria. This is unrelated to allergy (no IgE production involved) but rather is due to mast cell sensitivity to cold, with exposure to lower temperatures resulting in mast cell degranulation and formation of hives. There may be an autoimmune component. There are no features on history or physical examination today concerning for an underlying autoinflammatory syndrome. Most patients have spontaneous resolution of symptoms within a few years. In adults with cold urticaria, the agerage symptom duration is ~7 years. [Patient First Name] [has/has not had] systemic symptoms concerning for anaphylaxis, which is a risk in this condition, particularly when swimming in cold water. The epinephrine autoinjector should be available at all times. Technique and indications for use were reviewed, and a written anaphylaxis action plan has been provided. I have recommended avoidance or caution of swimming outdoors. Most patients with cold urticaria can tolerate water temperatures of 25° and higher (indoor swimming pools are typically above ethis). Prophylaxis with 2nd generation antihistamines (cetirizine, loratadine, fexofenadine, desloratadine, bilastine, rupatadine) may be helpful ahead of anticipated exposures, though does not prevent systemic symptoms.] [If includes Adverse reaction to contract media Adverse reaction to contrast media. [Patient First Name] experienced [immediate/delayed] onset symptoms, including [describe symptoms], following administration of radiocontrast media. [Thank you for including the relevant records/Relevant records have been requested to verify contrast media type, timeline and symptoms]. Reactions to contrast are not due to an IgE-mediated reaction, and instead are considered "pseudoallergic", secondary instead to physical characteristics of the dye (e.g. osmolarity and ionicity). Skin prick and provocation testing are not indicated. Prevalence ranges from 0.5-3%. Risk of reaction with future contrast exposures can be minimized with the following interventions: (1)Use of nonionic iso- or low osmolal contrast material (iso is preferred) (2)Premedication with (a)Prednisone 50 mg at 13, 7, and 1 hour prior to contrast administration (b) Diphenhydramine 50 mg po or I.V. 1 hour prior to contrast administration Physicians and facilities administering contrast should have the capability to manage anaphylaxis in the event that it occurs (unlikely with premedication). [Patient First Name] should remain at the facility for 1-2 hours following the scan for observation. ] [If Chronic idiopathic urticaria and angioedema Chronic idiopathic urticaria and angioedema. [He/she/they] [have/has] a 3-4 year history of symptoms and meets criteria for the diagnosis. I explained that this is an autoimmune, rather than allergic, condition. I recommended that [he/she/they] avoid known exacerbating factors (NSAIDs, stress, alcohol, heat, pressure). The natural history is excellent; most patients have resolution of their symptoms within 2 years. In some, however the disease can persist for much longer. The goal of therapy is to minimize symptoms until the disease spontaneously remits. Non-sedating antihistamines (loratadine, desloratadine, fexofenadine, cetirizine) can be given up to 4X the recommended dose, aiming for the lowest effective amount needed.] [If no current evidence for allergy to medication No current evidence for allergy to [penicillins/amoxicillin/penicillin/cephalexin/azithromycin/clarithromycin/trimethoprim-sulfamethoxazole/clindamycin/metronidazole]. The history of [delayed rash/other] was not concerning for life-threatening immediate or delayed type allergies. [Patient First Name] tolerated an oral challenge today, definitively ruling out IgE-mediated allergy to this [class of medications/medication]. [Patient First Name] will contact the clinic if [she/he/they] [notices/notice] any delayed reactions, such as rash. [I noted that there is a 5-10% recurrence rate for delayed rashes with amoxicillin; providing there are no signs or symptoms concerning for life-threatening delayed forms of drug allergy (SJS/TEN, DRESS, serum sickness, etc.) this is not a contraindication to subsequent courses.] I will submit a form to PharmaNet to remove this label from the provincial record. [Patient First Name] can have this medication in the future if clinically indicated. We reviewed signs and symptoms of immediate (hives, swelling, problems breathing, vomiting, lethargy) and delayed (desquamation, mucus membrane involvement, fevers) reactions that should prompt discontinuation of a medication, presentation to a health care provider, and a later return to our clinic for review. ] [If Food Allergy Food allergy. [Patient First Name] is [presumed] allergic to [peanut/almond/hazelnut/cashew/pistachio/walnut/pecan/Brazil nut/macadamia nut/pine nut/pea/chickpea/sesame/lentil/kiwi/egg/cow’s dairy] based on a history of reaction ([hives/swelling/flushing/vomiting/diarrhea/lethargy/cough/sneezing/breathing difficulties]) and positive testing ([3/4/5/6/7/8/9/10/11/12] mm). I have requested serum IgE testing to provide a baseline. For now, [she/he|/hey] should avoid [peanut/walnut & pecan/cashew/pistachio & almond/hazelnut/pine nut/macadamia nut/sesame/chickpea/lentil/egg in cooked and raw form/dairy in raw forms/kiwi], and the epinephrine autoinjector must be available to [her/him/them] at all times. Technique and indications for use were reviewed, and a written anaphylaxis plan has been provided. Without intervention, we expect only [10/20]% of patients to outgrow [peanut/tree nut/sesame] allergy. The natural history for [milk/egg] allergy [is/are] excellent; most patients will outgrow [this allergy/these allergies] by school age. I have given the family a copy of the [milk/egg] [ladder/ladders], which [outline/outlines] progressively more allergenic forms of the food. [Patient First Name] should start by trying extensively baked [milk/egg] and can gradually work up the ladder to more allergenic forms of the [food/foods]. [Patient First Name] is a candidate for oral immunotherapy, an emerging therapy for food allergy that involves giving children small amounts of their allergen. This can reduce the risk posted by accidental exposures and, in preschool aged children, may alter the natural history of the disease. I have provided parents with written information about this today. ] [If Food Introduction Food introduction. [Patient First Name] is at risk for IgE-mediated allergy based on the following: [personal history of atopy/first degree family history of atopy/skin barrier disorder (atopic dermatitis, keratosis pilaris, ichthyosis vulgaris/history of probable allergy to one or more foods]. The main intervention for prevention of food allergy is early introduction of allergenic foods followed by regular exposure. I’ve provided parents with a handout from the Health Link BC website regarding allergy prevention. I’ve recommended that [Patient First Name] try the following foods: [peanut/almond/hazelnut/cashew/pistachio/walnut/pecan/Brazil nut/macadamia nut/pine nut/pea/chickpea/sesame/lentil/kiwi/egg/cow’s dairy/soy/wheat/fish/shellfish]. Parents are [comfortable/not comfortable] introducing new foods in the home environment. We will therefore see [Patient First Name] back [for observed ingestions of food in the clinic/to review success of home food introduction]. Once introduced, these foods should be eaten regularly to promote tolerance. We discussed signs and symptoms of IgE-mediated allergy that should prompt discontinuation of a food, treatment, and a later return to the clinic for review.] [If Food protein induced enterocolitis syndrome (FPIES) Food protein induced enterocolitis syndrome (FPIES). [Patient First Name] has a history of [delayed onset recurrent vomiting/ ] after [ ]. The history is in keeping with FPIES. This is a delayed form of food allergy that is thought to be (at least in part) T cell mediated, although the pathophysiology remains incompletely understood. Clinical reactions always involve vomiting (typical onset 2-4 hours after ingestion), and 50% of patients have diarrhea that starts 1-2 hours after vomiting. A smaller subset of patients have concurrent pallor, lethargy and hypotension, sometimes requiring hospitalization and fluid resuscitation. Reactions have been [mild/severe]. The natural history of the disease is excellent; most children outgrow this within 2 years. Standard guidelines recommend strict avoidance pending a food challenge 18-24 months following the most recent reaction. An alternative approach includes reintroduction with very small amounts of the food followed by graduated advancement if tolerated (ladder approach). I generally offer this in patients with concurrent eczema, as avoidance of foods places them at increased risk of IgE-mediated allergy. I have prescribed ondansetron, [2/4/8] mg SL x 1 to be used PRN with onset of symptoms. I have provided a letter to provide to the emergency department outlining the condition, and have reviewed indications to seek medical attention (signs of hypotension). ] [If Food protein induced enterocolitis (FPIP) Food protein induced enterocolitis (FPIP). [Patients First Name]'s history of mucus and blood in the stool is consistent with FPIP, a form of delayed food allergy that involves inflammation of the distal colon triggered by dietary factors. Most children (85%) outgrow FPIP between 6-9 months of age, and 95% of children will have outgrown it by one year of age I have recommended the following foods are restricted by [Mother's First Name] and [Patients First Name]:[list of restricted foods]. I do not recommend maternal dietary restrictions beyond [4/5] days, and would instead proceed to a hypoallergenic formula if symptoms are severe or bothersome (on balance, I prefer tolerating some mucus and minimal blood in a well and growing baby rather than discontinuing breastfeeding). I'm hopeful that [Patient First Name]'s symptoms will clear with the elimination of [foods to be eliminated]. Once symptoms have stabilized, I've suggest reintroduction of each of the eliminated foods, to confirm which are truly the culprit and therefore avoid unnecessary restrictions. Once the trigger foods have been identified, they should be restricted from [Mother's First Name] and [Patients First Name] diet until ~9 months of age, after which time they can be introduced to see whether the condition has resolved.] [If Food pollen syndrome. Food pollen syndrome (formerly oral allergy syndrome). [Patient First Name] experiences oropharyngeal symptoms with [fresh fruits/legumes/tree nuts]. [She/He/They] [is/are] sensitized to [birch/grass/weed] [pollen/pollens], which [is/are] cross reactive. As the cross-reactive proteins are very susceptible to heat and acid degradation, the risk of a systemic reaction is quite low. In the absence of a history of severe swelling or systemic symptoms, I do not recommend carrying an Epinephrine Auto Injector. [The food/Foods] can safely be eaten in heated or processed form. I have provided [Patient First Name] with a handout to provide some additional information. [If Food intolerance. Possible food intolerance. [Patient First Name] has a history of symptoms that include [bloating/constipation/loose stools/nausea/abdominal pain/fatigue/irritability| ]. The differential diagnosis for these symptoms is quite broad. Symptoms could be related to food intolerance, which is an adverse reaction to food that is not mediated by the immune system. [Patient First Name]'s symptoms may be due to irritable bowel syndrome. [He/She/They] [report/reports] a history of abdominal discomfort at least one day per week over the past 3 months. Symptoms [are/are not] related to bowel movements, and [she/he/they] [has/has note/have/have not] observed changes in [stool consistency/stool frequency]. I have made the following lifestyle recommendations: -Daily cardiovascular activity -Regular meal and bathroom routines -Regular sleep schedule We discussed interventions that have some evidence in the treatment of irritable bowel syndrome, which can be tried one at a time (I suggest 1-3 month trials of each): -Probiotics (Visbiome, BioGaia are both good options) -Peppermint oil capsules (available on Amazon or health food stores) -Low FODMAPs diet (I've provided multiple handouts on this) [Patient First Name] is concerned that symptoms may be related to specific foods. I have therefore recommended that they keep a food and symptom diary for the next 2-4 weeks, and also note other factors that may contribute (caffeine, alcohol, exercise, sleep, stress, and fluid consumption). On review, it is also helpful to look not just at specific foods, but also the overall composition of meals (for example, meals that are higher than typical in sugar or fat). If [she/he/they] [identifies/identify] any possible contributing foods or factors, they can try eliminating and then reintroducing these one at a time. I have advised against any extensive elimination diets, as well as any prolonged eliminations of specific foods, which can contribute to the development of IgE-mediated allergy (particularly in patients with atopic disease). If [Patient First Name] identifies foods that trigger symptoms, I recommend that these are minimized (rather than completely eliminated) from the diet. [Symptoms are consistent with lactose intolerance. I explained that this was unrelated to allergy, and instead is caused by an inability to break down lactose. As a result, this sugar cannot be absorbed, and it remains in the gut where it attracts water and is consumed by bacteria, leading to gas production, abdominal discomfort, and diarrhea. Although a hydrogen breath test could be ordered if the patient wishes, it's generally easier simply to do a trial of lactose free dairy products to see whether symptoms remit compared to lactose containing forms. I've provided the patient with additional information regarding lactose concentration of various foods from unlockfood.ca. Lactase supplements may be beneficial.]] [If Perioral rash. Perioral rashes. [Patient First Name] has had perioral [and beard distribution] rashes after contact with foods containing dairy. Rashes have been limited to points of contact, and [she/he/they] [has/have] not had clear IgE-mediated symptoms. Overall, the history is most in keeping with an irritant, rather than allergic reaction. Application of a barrier prior to eating will help (but won't completely prevent the rashes). Maintaining a healthy skin barrier will also reduce the frequency of rashes. I explained that rashes limited to contact can be disregarded and are not a contraindication to ongoing exposures to the food. We discussed signs and symptoms of IgE-mediated allergy that should prompt discontinuation of a food, treatment, and a later return to the clinic for review.] [If Keritosis Pilaris. Keratosis pilaris. This is a benign, autosomal dominant condition that is caused by dead skin cells plugging up hair follicles. I referred [Patient First Name] to the DermNetNZ website for additional information. No specific therapy is indicated. However, if the appearance is bothersome, emollients that contain keratinolytics (urea, lactic acid) can be helpful when applied regularly. Higher strength compounded topicals can be considered in severe cases.] [If Mastocytoma. Mastocytoma. This is the most common form of cutaneous mastocytosis, and is an accumulation of mast cells in the superficial dermis. Activation (by one of many triggers, they're very twitchy cells!) results in release of histamine and other mediators leading to erythema, swelling, and pruritus (urtication). Typical onset is 0-3 months of age, and they generally disappear prior to puberty. Systemic symptoms (anaphylaxis) are exceedingly rare. In the presence of a classic Darier's sign, investigations (biopsy) are not required. Management is symptomatic, and we recommend avoiding known triggers of mast cell degranulation, including: excessive heat, friction/pressure, stress (challenging to avoid tantrums in a toddler), and NSAIDs. Non-sedating antihistamines (loratadine, desloratadine, fexofenadine, cetirizine, bilastine, rupatadine) can be used PRN to manage pruritus (though most patients need these infrequently). We recommend against use of diphenhydramine given the poor side effect profile and short duration of action.] [If Non-allergic rhinitis. Non-allergic rhinitis. [Patient First Name] has a history of symptoms that include [rhinorrhea/congestion/post-nasal drip/throat clearing/nasal pruritus/ocular pruritus]. Skin prick testing today is negative, suggesting against an allergic cause for [his/her/their] symptoms. The differential includes local allergic rhinitis (IgE-production limited to the nasal mucosa, not detectable on skin prick or serum IgE testing), non-allergic rhinitis with eosinophilia (NARES), vasomotor or irritant rhinitis, and infectious rhinitis. There [are/are no] features on history or physical concerning for vasculitis. [ /I have recommended additional bloodwork, including:[specific blood work].] I have provided [Patient First Name] with written information about non-allergic rhinitis. Regardless of the underlying cause, persistent nasal congestion can be managed with a regular intranasal steroid, used [1/2] [spray/sprays] per nostril [OD/BID]. Antihistamines are of uncertain benefit, but may provide a drying effect. For vasomotor rhinitis, [he/she/they] can try ipratropium nasal spray used PRN, 1-2 sprays per nostril Q 4-6 hours.] [If Periorifical dermatitis. Periorifical Dermatitis. History and examination [of photographs/] are in keeping with periorificial dermatitis, with erythematous papules localized to [the nasolabial folds/around the eyes], which are exacerbated by irritant exposures. This is a common inflammatory skin eruption (much like rosacea) that is localized to areas around the eyes, nostrils and mouth. Risk factors include steroid use (including inhaled medications), application of personal care products or cosmetics, and exposure to irritants including toothpaste and sunscreen, and physical factors including UV, heat, cold, and wind. It is more common in those with underlying atopy. The condition is benign and self-resolving. We discussed the "zero therapy" approach, with avoidance of irritants, discontinuation of topical steroids, and gentle rinsing after exposures to inhaled steroids and sunscreen. Thick emollient application in affected areas should be avoided. If the rash is bothersome, topical therapies include topical calcineurin inhibitors (pimecrolimus, tacrolimus) applied BID, and metronidazole cream. Treatment times are generally 3-4 weeks. We have sent the link to DermNet NZ to provide additional information.] [If Skeeter Syndrome. Large swelling with mosquito bites. [Patient First Name] has a history of large local reactions after mosquito bites. This is more common in young children, and is occasionally seen in adults as well (particularly after exposure to different species of mosquitos/different areas of the world - the typical history is abnormally large reactions in a traveller). This sometimes goes by the label "Skeeter Syndrome", although fortunately [Patient First Name] did not have any associated systemic symptoms. The history is not concerning for IgE-mediated allergy to mosquito (which is extremely rare). I suspect the location of the bites contributed to the extensive swelling. While benign, the condition can be quite alarming. I've suggested prophylactic use of 2nd generation antihistamines (loratadine, desloratadine, fexofenadine, cetirizine, rupatadine) taken ahead of anticipated exposures (eg daily while camping, a few hours prior to a backyard bbq, etc.). Once bites are already present, there is little we can do to alter the natural history. This condition should improve gradually over time. I reassured parents that [Patient First Name] is not at any increased risk for systemic reactions with other types of insect stings.] [If Sublingual immunotherapy (SLIT). The risks and benefits of therapy were reviewed, and verbal informed consent was obtained. [Patient First Name] was given [Oralair 300 IR SL x 1/Grastek 2800 Units SL x 1/Acarizax 12-SQ-HDM SL x 1/Itulatek 12-SQ Bet SL x 1]. [She/He/They] [was/were] observed for 30 minutes. [She/He/They] reported symptoms that included [oropharyngeal pruritus/swelling|ocular pruritus/ear pruritus/dyspnea/other]. Symptoms resolved within [15/30/60] minutes. ] Allergic rhinitis ([grass pollen/tree pollen/weed pollen/dust mite/cat/dog/molds]). [Patient First Name] has tolerated [her/his/their] first dose of sublingual immunotherapy (SLIT) for [grass pollen/tree pollen/dust mites] today. [She/He/They] will continue to take this dose SL daily. [She/He/They] must avoid swallowing for 1 minute after the dose, and eating and drinking should be avoided for at least 5 minutes after the dose. Local side effects, including pruritus and swelling, are common. If bothersome, a non-sedating antihistamine (cetirizine, loratadine, desloratadine, fexofenadine) can be taken 1-2 hours prior to the dose. Symptoms should improve over the first few weeks of therapy. Dosing will be [year round/6-12/8-12]. A three year treatment course is recommended, but need for ongoing therapy will be evaluated annually. [Patient First Name] is likely to require [1/2/3] additional year[s] of therapy. If [Patient First Name] has bothersome symptoms despite this therapy, we can consider a transition to subcutaneous immunotherapy.] [If Serum sickness like reaction (SSLR). Serum sickness like reaction (SSLR). [Patient First Name]'s history of [ ] is most in keeping with a diagnosis of SSLR, which is an immunologic condition characterized by skin rash and arthralgias, with or without fever. Additional symptoms can include malaise, abdominal pain, nausea, vomiting, lymphadenopathy and headaches. Symptoms can present days to weeks after exposure to the trigger. These reactions have a variety of potential triggers, including exposure to infectious agents (e.g. viral illness, some vaccines, streptococcus) In cases where the underlying etiology is uncertain, I recommend a challenge (previously I did three day but recent study suggested single dose is nearly as effective) to the culprit medication. I'll provide the family with a requisition for investigations that can be done with symptom onset (BUN, Cr, CRP, C3, C4, CH50, urinalysis) In this case, Haya has had 2 exposures to the medication with similar outcomes. There are no reports of successful desensitization to amoxicillin in the context of SSLR, and in general this would not be recommended given the underlying pathophysiology (non-IgE-mediated reaction). There is no published data regarding the natural history. It would be reasonable to consider a challenge in 3-5 years to see whether this label could be removed from [her/his/their] record.] [If Local reaction with insect stings. Local reaction with insect stings. [Patient First Name] experienced a [large/small] local reaction following an insect sting. Fortunately, this history does not place [Patient First Name] at increased risk of a systemic reaction going forward, and so intradermal testing and venom immunotherapy are not indicated. I do not recommend EpiPen carriage; however, if there is considerable anxiety this could be considered, particularly when on camping or long hikes. [I suggested that they carry their current pen until it expires and then discontinue it.] [Patient First Name] may have similar reactions with subsequent stings. Non-sedating antihistamines (cetirizine, loratadine, desloratadine, fexofenadine, rupatadine, bilastine) can be used as needed for pruritus. If swelling is severe leading to impaired ambulation, naproxen (or other NSAIDs) can be helpful to reduce discomfort. Systemic steroids can be used in extreme cases, but do little to alter the natural history of the swelling, which persists for 1-2 weeks. Antibiotics are not indicated. We reviewed the following avoidance measures: -Avoid walking outdoors barefoot -Exercise caution when eating or drinking outdoors -Avoid straws and cans -Wear gloves and long-sleeved shirts when gardening or playing in high-risk areas -Remove insect nests from around the home We reviewed signs and symptoms of anaphylaxis. If [Patient First Name] experiences these with a subsequent sting, the EpiPen should be immediately prescribed, and I would like to see them back for testing and consideration of venom immunotherapy.] [If Anaphylaxis with insect stings. Anaphylaxis with insect stings. [Patient First Name] experienced anaphylaxis following an insect sting. Based on the history and testing, the most likely insect was [yellow jacket/yellow faced hornet/white faced hornet/honey bee/wasp]. We reviewed avoidance measures, including: -Avoid walking outdoors barefoot -Exercise caution when eating or drinking outdoors -Avoid straws and cans -Wear gloves and long-sleeved shirts when gardening or playing in high-risk areas -Remove insect nests from around the home As the risk of anaphylaxis with a subsequent sting is high (30-60%), I have recommended treatment with venom immunotherapy to reduce the risk of anaphylaxis with subsequent sting to 5% or less. I will place the order for this today, and we will contact [Patient First Name] once it has arrived to arrange for their injections. I recommend a build up protocol that will allow us to reach maintenance dosing (and be protected) within 4 weeks. [Patient First Name] will require weekly visits ×4, followed by monthly visits for 1 year. After 1 year at maintenance dosing, injections should be given every 2 months for a total of 4-5 years. [Patient First Name] should carry an EpiPen until [he/she/they] [reach/reaches] maintenance dosing, after which it is no longer required, unless [he/she/they] [is/are] traveling to areas with poor access to health care assistance. ] Output Format: [Problem 1: detailed impression and plan in sentence format] [Problem 2: detailed impression and plan in sentence format] [Do not hallucinate. Use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank.]

Follow Up

[Provide follow up instructions that have been provided to the patient, do not make assumptions.] [I have not made formal arrangements for follow up/I would like to see the patient back [State the timing of follow up appointment, which may include a specific period of time that has elapsed after this appointment, or a period of time that has elapsed after further testing is completed][for reason for follow up][, or sooner [specify under what conditions to return earlier (only include if applicable)]. It was a pleasure to meet with [patient first name] today. Thank you again for allowing me to take part in [patient pronoun] care. Please call if there are any questions or concerns.