Allergy & Immunology Consultation

John Doe is a 35-year-old male referred for evaluation of possible allergic rhinitis. **Atopic history:** John has been experiencing nasal congestion, sneezing, and itchy eyes for the past two years, particularly during the spring and fall seasons. Symptoms are exacerbated by exposure to pollen and dust. Otherwise, he has no known food, drug, or venom allergies. He also denies symptoms suggestive of atopic dermatitis, asthma, or allergic rhinitis. **Past Medical History:** - Hypertension - Seasonal allergies - Eczema - Gastroesophageal reflux disease (GERD) **Medications:** - Lisinopril 10mg daily - Loratadine 10mg daily - Omeprazole 20mg daily **Social History:** - Non-smoker - No recreational drug use - Software engineer - Covered under Blue Cross Blue Shield - Owns a cat **Family history:** - Mother with allergic rhinitis - No known family history of immunodeficiencies, lung diseases, autoimmune or connective tissue diseases - No family history of angioedema **On examination:** - Nasal examination: Swollen turbinates with clear discharge - Chest examination: Clear to auscultation bilaterally - Dermatological examination: No rashes or lesions noted **Skin Prick Testing:** - Positive for grass and dust mite allergens **Spirometry:** - Normal spirometry results **Impression/Plan:** John Doe is a 35-year-old male with a history of allergic rhinitis. Skin prick testing confirmed sensitivity to grass and dust mites. I have recommended environmental control measures and continuation of loratadine. I have also prescribed a nasal corticosteroid spray for better symptom control. Follow-up is arranged in 6 months to assess response to treatment. Thank you very much for the referral. If there are any questions, please feel free to contact me. This note was generated with the assistance of an AI scribe. Consent obtained before initiation of session.