Scribe BC - Allergy and Immunology Consult

Scribe BC - Allergy and Immunology Consult Dear Dr. Smith, Thank you for referring this pleasant 35-year-old female for allergy/immunology assessment. She was seen in person. **History of Presenting Illness:** Rhinitis: The patient reports experiencing rhinitis symptoms for the past 6 months, with a perennial pattern. She identifies dust mites and pollen as triggers. She has tried over-the-counter loratadine, which provided some relief. She has not seen an otolaryngologist. Asthma: The patient was diagnosed with asthma 5 years ago. She experiences dyspnea, chest tightness, and coughing. Her most recent pulmonary function test was 6 months ago, with results showing mild airway obstruction. She has nocturnal symptoms approximately once per month and experiences some functional limitations during exercise. She has had two exacerbations in the past year, requiring albuterol inhaler use. She is currently taking a combination inhaler, and is followed by a respirologist. Adverse Food Reactions: - Peanut - Age of patient at time of reaction: 2 years old - Size of ingested serving, and specific food ingested: A small amount of peanut butter - Symptoms after ingestion, including symptom timing and duration: Hives and swelling of the lips, lasting for approximately 1 hour. - Whether patient proceeded to hospital, and any additional symptoms during transport: No hospital visit was needed. - Symptoms upon arrival at the Emergency Department (ED): N/A - Specific medicine(s) given, who it was given by, location where it was administered (home, hospital): Diphenhydramine was given at home by her mother. - Symptoms that improved or resolved, including timing of improvement or resolve: Hives and swelling resolved within 1 hour. - Whether symptoms have reoccurred: No. - Whether any specific testing was completed previously, including specific test results: Skin prick testing was performed, showing a positive reaction to peanut. - 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: None. - Any additional treatments prescribed previously (e.g., food ladder): None. - Whether patient has an epinephrine auto-injector, include brand, type, and whether they have training devices available: Yes, EpiPen, and has training devices available. Eczema or Atopic Dermatitis: The patient was diagnosed with eczema at age 10. The affected areas are primarily on the elbows and knees. She experiences flares approximately once per month. She uses Cetaphil moisturizer daily. She has tried topical corticosteroids, which provide some benefit. Her current medication plan includes topical hydrocortisone during flares. She has had no prior skin infections or dermatologist evaluations. Rash or Urticaria: The patient reports a rash history, with the first onset of the rash occurring 2 years ago. She experiences episodes approximately once per month. The rash presents as raised, itchy welts on the trunk and extremities, each lasting for several hours. There are no residual findings on the skin after the rash resolves. Associated symptoms include mild itching. She has used loratadine, with some improvement. She has not had prior dermatologist evaluations or a biopsy. Drug Allergy: The patient reports an allergy to penicillin, with the reaction occurring at age 5. The drug was administered orally for a throat infection. She took one dose before the reaction. The symptoms included hives and itching, lasting for several hours. She was treated with diphenhydramine. She did not proceed to the hospital. She has not tolerated penicillin or related antibiotics since. No specific testing was completed previously. Other Problems: None. **Past Medical History**: Otherwise healthy. **Current Medications:** Loratadine 10mg daily, albuterol inhaler PRN, combination inhaler twice daily. **Stinging Insect Reactions:** None reported. **Adverse Drug Reactions:** Penicillin allergy. **Family History**: Noncontributory. **Social History**: The patient has a cat at home, does not smoke, and works as a teacher. She has extended medical insurance. **Physical Examination:** **Head and Neck**: Oropharynx was clear. **Chest**: No wheezing. **Skin**: No rash. **Skin Testing:** **Inhalants**: **Positive reaction to**: dust mite, cat, tree pollen, grass pollen **Negative reaction to**: mold **Foods**: **Positive reaction to**: peanut, milk **Negative reaction to**: egg **Histamine control**: Normal. **Dermatographism**: Skin testing was complicated by dermatographism. **Investigations:** **Bloodwork**: 1 November 2024: sIgE testing pending. **Imaging**: None. **Procedures**: None. **Assessment and Plan:** **Allergic rhinitis**: Skin prick testing today was unreliable, and I will further investigate with sIgE testing. Avoidance measures were reviewed, and written information provided. Non-sedating antihistamines, nasal corticosteroids, and antihistamine eye drops can be used for symptom relief. Prescription for: loratadine was provided. The patient is a good candidate for immunotherapy if symptoms become medically refractory, or if allergy modifying therapy is desired. Based on the pattern of sensitization, the patient is a candidate for subcutaneous immunotherapy. The patient will contact my clinic directly for follow-up if the patient become interested in immunotherapy. **Subcutaneous immunotherapy**: The patient is interested in pursuing subcutaneous immunotherapy. There is typically 6-9 months of weekly build-up injections, followed by monthly maintenance injections. Benefit is expected within 1-2 years. A typical course is 3-5 years, after which there should be lasting effect. Risks include life-threatening anaphylaxis were discussed. A prescription has been prepared. Once the serum is available, a follow-up visit will be arranged for first injection. The patient can then continue to receive injections with me, or with yourself if you agree. **Potential allergic rhinitis**: In person follow-up will be arranged for skin testing. Requisition was provided for sIgE testing to identify sensitization pattern. Non-sedating oral antihistamines, intranasal corticosteroids, antihistamine eye drops can be used for empiric symptom relief. A prescription for loratadine was provided. Immunotherapy may be an option. **Asthma**: Asthma, poorly controlled. Pre- and post-bronchodilator spirometry requisition was provided. Recommended treatment: Symbicort 200mcg 1 inh BID + PRN. Written asthma action plan was provided. Poorly controlled asthma is a contraindication for immunotherapy. Routine vaccination, including with influenza, COVID-19 and RSV, is recommended if applicable. The patient is a candidate for biologics given frequency of exacerbations. Requisition was provided for screening bloodwork to determine eligibility. **Food allergy**: Allergy to peanut. History, skin testing results, and sIgE results support a diagnosis of IgE-mediated allergy. Requisition was provided for confirmation with sIgE testing. Strict avoidance was recommended. Epinephrine autoinjector should be carried at all times. EpiPen (Jr) was prescribed. **Atopic dermatitis**: Principles of eczema management were reviewed and written information was provided. Regular moisturizing was recommended for prevention of flares. Topical medications should be aggressively used when flares develop, to minimize complications such as post-inflammatory hyperpigmentation and skin infections. Prescription for: hydrocortisone was provided. **Chronic spontaneous urticaria**: Up to 40% of patients will also develop non-life-threatening angioedema that does not involve the larynx. The patient also has symptomatic dermatographism, a form of chronic inducible urticaria triggered by pressure on the skin. Chronic nature of the condition was reviewed. In many individuals this condition is due to an autoimmune process in which autoantibodies our directed against the mast cells. This is a self-limiting condition but can take months to years to subside. Blood work for associated conditions has been ordered. Management is aimed at symptomatic control. The medications should continue to be used until the urticaria spontaneously resolves. First line treatment is with non-sedating antihistamines at up to 4x labelled dose. If not responding to high-dose antihistamines than omalizumab or cyclosporin would be options. Short course of oral corticosteroids can be used for severe exacerbations. A prescription for loratadine was provided. Advised to avoid NSAIDs and alcohol which can exacerbate the condition. **Penicillin allergy**: Penicillin allergy is commonly reported (around 10% of the population), but most patients with a penicillin allergy label can tolerate penicillin. This is most commonly secondary to misattributed symptoms due to other comorbidities. Sensitization can also be lost over time (80% in 10 years). A penicillin allergy label is associated with multi-drug resistant organisms, and prolonged hospital stays. Given remote reaction with low risk features, direct oral amoxicillin challenge is recommended. Amoxicillin will be administered, and the patient will be monitored for 1 hour for features of immediate hypersensitivity. The risks and benefits were discussed, and the patient is agreeable with proceeding when they returns in follow-up. If they is asymptomatic, they has the same risk of penicillin allergy as the general population, and the allergy label can be removed. **Follow-up**: Follow-up in 3 months. Thank you for the opportunity to be a part of his care. Please do not hesitate to contact with any questions or concerns. _"The patient provided verbal consent to use the AI scribe during this visit, understanding its purpose, potential benefits, and as well as any associated privacy and security risks."_