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Allergy and Immunologist Template

Immunology follow-up note

A professional Allergy and Immunologist template for healthcare professionals.
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About this template

Need a clear and concise way to document patient progress in immunology? This **Immunology Follow-up Note** template is designed for allergy and immunology specialists. It helps you efficiently record key information like current treatments, infection history, and lab results. This template ensures you capture all the essential details of a follow-up visit, from patient satisfaction with therapy to plans for future care. With Heidi, this template can be quickly populated from your visit transcript, saving you time and improving the accuracy of your medical documentation.

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**(Use gender-specific pronouns (he/him or she/her) based on the patient's gender. Only use they/them if gender information is unavailable.)** **Summary of Clinical Problems and Diagnoses** Patient presents with a history of recurrent upper respiratory infections and suspected primary immunodeficiency. Confirmed diagnosis of Common Variable Immunodeficiency (CVID). **Current Therapy** Patient is currently receiving intravenous immunoglobulin (IVIG) infusions every three weeks at a dose of 400mg/kg. He is also taking prophylactic antibiotics, trimethoprim-sulfamethoxazole, 80/400mg, twice weekly. **Summary of Progress Since Last Visit** Patient reports a decrease in the frequency of upper respiratory infections since the last visit. He has experienced one mild cold in the past three months, which resolved without complications. No hospitalisations since the last visit. **History of Infections** Patient has a history of recurrent sinopulmonary infections, including pneumonia and sinusitis, prior to diagnosis and treatment with IVIG. He has also had a history of oral thrush. **Satisfaction with Current Therapy and Adverse Reactions** Patient reports being satisfied with the current therapy. He denies any significant side effects from IVIG infusions. He reports mild fatigue on the day of the infusion. **Results of Investigations** Recent laboratory results show an improvement in IgG levels, now at 850 mg/dL (normal range: 700-1600 mg/dL). Flow cytometry shows stable B-cell and T-cell counts. **Advice Regarding Treatment** Advised the patient to continue with the current IVIG regimen and prophylactic antibiotics. Discussed the importance of adherence to the treatment plan. Reviewed signs and symptoms of infection and when to seek medical attention. Shared decision-making regarding the timing of the next infusion. **New Investigations Ordered** No new investigations ordered. **Summary of Progress** Overall, the patient is showing good progress with a reduction in the frequency of infections and improved IgG levels. His current clinical status is stable. **Interval to Next Follow-up** Next follow-up appointment scheduled in three months, on 1 February 2025.
**(Use gender-specific pronouns (he/him or she/her) based on the patient's gender. Only use they/them if gender information is unavailable.)** **Summary of Clinical Problems and Diagnoses** [Summarize the patient's main clinical problems and confirmed diagnoses] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Current Therapy** [Describe current therapy or treatment being undertaken, including medications, dosages, frequency, or any non-pharmacological treatments] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Summary of Progress Since Last Visit** [Provide a summary of the patient's progress since the previous visit, including any improvements, persisting symptoms, or relapses] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **History of Infections** [Describe any reported infections or relevant infectious disease history, including timing, treatment, and outcomes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Satisfaction with Current Therapy and Adverse Reactions** [Document the patient's satisfaction with ongoing therapy, including any reported side effects, adverse reactions, or tolerance issues] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Results of Investigations** [Summarize any recent laboratory, imaging, or diagnostic test results, including relevant interpretations if discussed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Advice Regarding Treatment** [Include advice provided to the patient regarding continuation, modification, or cessation of current treatment, including rationale and shared decision-making elements] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **New Investigations Ordered** [List any new investigations or tests ordered during the current visit] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Summary of Progress** [Provide an overall summary of progress, including current clinical status and comparison to prior assessments] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Interval to Next Follow-up** [State the interval or timing for the next follow-up appointment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Never come up with your own patient details, assessment, diagnosis, plan, interventions, evaluation, or next steps — use only the transcript, contextual notes or clinical note as a reference for the information included. If any information related to a placeholder has not been explicitly mentioned, do not state that it was not mentioned; simply omit the placeholder or section entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)
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Specialty

Allergy and Immunologist

Used

4 times

Type

Note

Last edited

31/10/2025

Created by

dinakantha kumararatne

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