Patient Referral and Follow-Up

Chief Complaint

Patient Referral and Follow-Up

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Thank you for your kind referral of Patient [name], a [age] male, seen [date] in the Allergy Clinic. I was grateful to have the helpful referral note. Patient was accompanied to today's visit by [pronoun] mother, [name]. Today’s appointment took place via telehealth ([url]). [Pronoun] mother was happy to proceed with use of the technology. PROBLEM LIST: 1. Possible food allergy to peanuts + reaction to unknown food Patient reacted after [pronoun] first exposure to peanut butter (~1 tsp; [age] of age [date]). Patient had a reaction within [duration]. There was a rash on whole face, extending from forehead to upper chest. The rash was a mix of erythema and raised erythematous lesions that were pruritic. There was also periorbital swelling and new onset sneezing. There were no other signs of respiratory distress, nor any other symptoms of anaphylaxis. The reaction resolved without intervention within [duration]. Patient received [drug_name] PO x2 at home. They did not present to [hospital] and do not have an epinephrine autoinjector. There was another reaction within [duration] of eating 'tacos' (ground turkey, no spices, pita, onion, avocado). [Pronoun] developed a raised, erythematous, pruritic rash that was migratory across trunk and face. There was also sneezing. There was no angioedema, additional respiratory distress, vomiting, diarrhea, or hypotensive symptoms. [Pronoun] was not given avocado again. They have re-introduced cheese. 2. Atopic dermatitis (eczema) Patient had onset of eczema in early infancy. Patient scratches throughout the night even when there is no clear eczema flare. [Pronoun] sheets are frequently bloody in the morning. [Pronoun] back is most affected, as well as face and flexural surfaces of legs. This is an improvement from previous full-body involvement. There have been no superinfections. They apply [drug_name] ointment [dosage] and [drug_name] ointment [dosage] in a thin layer to affected areas once daily at bedtime when there is a significant flare. With moderate flares, they avoid steroids due to concern of excessive steroid exposure. They did a [duration] course of [drug_name] [dosage] once for a bad outbreak on [pronoun] face. When they aren't using topical steroids, they apply [drug_name] and [drug_name] eczema lotion liberally at bedtime (previously up to TID when [name] was on parental leave). Baths occur [frequency]. They use [drug_name] soap in the bath (sudsy). [Pronoun] mother is worried about a possible dairy sensitivity contributing to [pronoun] sensitive skin. Patient was initially breastfed. They tried to transition to formula at [age], but [pronoun] was having varied reactions including eczema and generalized urticaria. [Pronoun] did better after transitioning to a hypoallergenic formula from [country]. Patient is now on homo milk for [duration], during which time there has been no clear reaction. [Pronoun] eczema continues to wax and wane, but not in temporal association with milk introduction. They also previously had a dog and wondered if allergens from the dog contributed to [pronoun] skin symptoms. They eventually re-homed the dog as a result and feel that [pronoun] skin has been overall improved since. 3. New non-urticarial rash Started [date]. Concurrent URTI sx for [duration]. Red raised papules over trunk, sparing face and extremities. The family noted the rash after Patient came out of the bath on [day]. It had been >[duration] since [pronoun] last food, which included no new foods. The family is not aware of any concerns for asthma, nocturnal coughing, or posttussive emesis. 4. Incomplete allergenic food introduction [Name] has been introduced to sesame, wheat, fish, shellfish, green pea, egg, lentil, soy, chickpea and coconut. These foods are maintained in [pronoun] diet on a regular basis. [Pronoun] has not been introduced to hazelnut, almond, cashew/pistachio, walnut/pecan, sesame, pine nut, Brazil nut, macadamia nut, or mustard. The reason for avoidance is fear based on [pronoun] previous reaction to peanuts and overall sensitive skin. ALLERGY REVIEW: Patient has extensive eczema, as outlined above. There was concern about possible allergy to dogs, as parents felt exposure to the family dog exacerbated [pronoun] eczema. The dog has now been re-homed. There is no history of reaction to medications, immunizations, or insect stings. They have not ever seen an allergist. PAST MEDICAL HISTORY: 1. Atopic dermatitis (eczema) 2. Suspect food allergies (peanuts) Perinatal history: Patient was born at term of a healthy pregnancy by planned cesarean section. [Pronoun] was well at birth, weighing [weight]. There were no complications during the neonatal period. Surgeries: none Development: Patient has met [pronoun] early developmental milestones appropriately. [Pronoun] pulls to stand and cruises. [Pronoun] says 'mama', 'dada', 'nana.' There are no parental concerns regarding vision or hearing. Care Team: Dr. [name] (PCP) MEDICATIONS: None ALLERGIES: There are no known allergies to medications. IMMUNIZATIONS are up to date. FAMILY HISTORY: [Pronoun] mother has 'sensitive skin.' [age] sister is healthy. [Pronoun] [age] sister had mild eczema that is now resolved, [pronoun] mother has mild eczema. [Pronoun] father has environmental allergies. There is no family history of asthma in the family. ENVIRONMENTAL HISTORY: Patient lives in a house that is [age] years old. There is no history of water damage or mold. There is carpeting in the home, including the bedrooms. They do not have any pets. There is forced air heating. Bedding is washed weekly. There is no smoking in the home. SOCIAL HISTORY: Patient lives with [pronoun] parents ([name] and [name]) and [age] sister. Patient attends infant daycare. [Pronoun] mother is a senior planner with the City of [city]. [Pronoun] father is a senior engineer tech for the town of [town]. They both have access to extended medical benefits. REVIEW OF SYSTEMS: Review of systems is non-contributory. PHYSICAL EXAMINATION: Complete examination was deferred today due to the telehealth appointment setting. Images provided were reviewed: 1) Reaction following peanut butter: erythema over central face 2) Rash following 'tacos': polymorphic, erythematous and raised lesions on trunk 3) Rash starting [date]: erythematous, round papules over trunk and face, less prominent on upper legs. INVESTIGATIONS: No investigations were performed today. IMPRESSION AND PLAN: 1. Food Allergy to Peanuts and Unidentified Trigger (?avocado) Patient is allergic to peanut based on a history of reaction (hives, swelling and sneezing). [Pronoun] had a similar reaction following ingestion of tacos containing avocado. Allergy testing will be deferred pending introduction of all allergenic foods. For now, [pronoun] should avoid peanut, and the epinephrine autoinjector must be available to [pronoun] at all times. Given the history, it would be reasonable to retry avocado starting with small amounts. A prescription for [drug_name] ([dosage]) was provided today. Technique and indications for use were reviewed. We ask that all individuals caring for Patient complete the Allergy Aware module (~[duration]) to build confidence with indications and technique for administering epinephrine. Without intervention, we expect only [percentage]% of patients to outgrow peanut allergy. Patient 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. We have provided parents with written information about this today. Prior to considering OIT, allergenic food introduction and adequate eczema control must be achieved. 2. Allergenic Food Introduction Patient can and should proceed with trying all allergenic foods, including hazelnut, almond, cashew/pistachio, walnut/pecan, sesame, pine nut, Brazil nut, macadamia nut, and mustard. They may also trial a small amount of avocado. We reviewed the pathophysiology of food allergies and how delayed introduction of allergenic foods increases the risk of developing a food allergy. 3. Atopic Dermatitis (Eczema) Patient has moderate eczema that currently impacts flexural surfaces of the limbs, the face and the torso. We 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. We recommended the following management plan: -Avoidance of detergent-based soap - babies do not need soap at all unless visibly dirty. -Frequent application of emollient (i.e., Vaseline), ideally TID. We discussed [pronoun] mother requesting daycare perform 1-2 applications per day -Hydrocortisone [dosage] ointment BID PRN for rash on the face, axilla and groin. Continue until [duration] after lesions are smooth and flat. They may then proceed with daily use of [drug_name], a steroid-sparing agent that is safe for daily use on the face. -Betamethasone valerate [dosage] ointment used BID PRN for rash on the body until flares are smooth and flat. -We request that parents take interval photographs of the rash before/during/after treatment to assess response. 4. New Rash and Prolonged Cough The rash that emerged on [date] is consistent with a viral exanthem. There is not temporal correlation with food introduction or associated systemic symptoms concerning for food allergy. The history of prolonged cough does raise the question of possible asthma. Patient has a strong atopic history and therefore is at higher risk of asthma. We asked parents to take note of duration of post-viral coughing, nighttime coughing, any signs of respiratory distress, or exercise induced systems. We will review this at a future appointment. FOLLOW UP: A follow up appointment has been booked in [duration] to review progress with food introduction, eczema management, and signs/symptoms consistent with asthma. It was a pleasure to meet with Patient and [pronoun] mother today. Thank you again for allowing me to take part in their care. Please call if there are any questions or concerns. Sincerely, PGY-1 Pediatrics with Dr. [name]