Rash

Introduction

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

History of Presenting Illness

[Provide a detailed narrative of the patient's experience with rash, including the duration from onset to resolution, frequency of episodes, and any associated symptoms such as lip or eyelid swelling. Describe any treatments used, including specific medications and doses, and their effectiveness. Note any consultations with dermatologists or allergists, and any history of contact dermatitis, eczema, or hives. Identify any precipitating factors such as stress, NSAID use, viral infections, new medications, or new skin care/hygiene products. Assess the severity of symptoms and note any absence of pain, scarring, bruising, or prolonged duration beyond 48 hours. Confirm the absence of systemic symptoms like fevers, weight loss, sweats, or joint pain. Include information on history of kidney, liver, thyroid disease, last bloodwork, testing for hepatitis and HIV, history of cancer, and history of dermatographia.]

Allergy Review

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

Past Medical History

[List the patient's past medical conditions and number them.] For example: 1. [Condition 1] - [Year] 2. [Condition 2] 3. [Condition 3] ...

Medications

[List the patient's current medications and number them.] For example: 1. [Medication 1] [Dosage/Instructions] 2. [Medication 2] [Dosage/Instructions] ...

Medication Allergies

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

Social History

[Provide details about the patient's social history, including smoking, alcohol use, occupation, and any relevant lifestyle factors. Provide details about extended health benefits.]

Environmental History

[Describe the patient's living environment, including details about the home, heating, presence of pets, frequency of bedding washing and any other relevant environmental factors.]

Family History

[List any relevant family medical history, particularly related to allergies 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.

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]

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.