Allergy Clinic Consultation Letter

Allergy Clinic Consultation Letter Letter to GP, copy to parents. Diagnosis 1. Cow's Milk Protein Allergy (CMPA) - IgE mediated, confirmed by positive specific IgE and immediate urticarial reaction upon ingestion. 2. Eczema - Atopic dermatitis, moderate severity, affecting face, antecubital fossae, and popliteal fossae. Examination Well-nourished 10-month-old infant, alert and interactive. Skin examination revealed erythematous, dry, and mildly lichenified patches over cheeks, antecubital and popliteal fossae, consistent with atopic eczema. No respiratory distress or wheeze noted. Capillary refill time less than 2 seconds. Abdominal examination was unremarkable. Peripheral pulses were strong and equal. Height 72 cm Current Medication 1. Hydrocortisone 1% cream, applied thinly to affected areas twice daily as needed. 2. Emulsifying ointment, applied as a daily moisturiser and soap substitute. 3. Cetirizine oral solution 2.5mg once daily as needed for pruritus. Investigations Skin prick tests were performed in clinic. Results were as follows: Cow's milk: 12mm wheal, positive control (histamine): 5mm wheal, negative control (saline): 0mm wheal. Specific IgE blood tests confirmed elevated levels to cow's milk protein (f2: 8.5 kU/L). Total IgE was also elevated at 150 kU/L. These results are consistent with an IgE-mediated cow's milk protein allergy. PLAN 1. Strict avoidance of cow's milk protein from patient's and breastfeeding mother's diet. Prescription for Neocate LCP (amino acid formula) provided as a supplement for the infant. 2. Continue with current eczema management, with a review of topical steroid strength if eczema flares persist. 3. Referral to Paediatric Dietitian for comprehensive dietary advice and support regarding cow's milk protein avoidance and introduction of solids. 4. Education provided on recognising signs of anaphylaxis and the use of an adrenaline auto-injector, although none prescribed at this stage given the history of mild reactions. Outcome Patient and parents were counselled regarding the diagnosis and management plan. A follow-up appointment has been scheduled for 6 months to review progress and discuss reintroduction of dairy under medical supervision. Dear Colleagues This letter concerns Eleanor, born 01/02/2024, who attended our clinic on 1 November 2024, accompanied by her parents, for further investigation of recurrent eczema and suspected food allergy, as per your referral. Eleanor is a 10-month-old female infant who presented with a history of persistent eczema since 3 months of age, poorly controlled with emollients and mild topical steroids. Her parents also reported immediate urticarial rashes and occasional vomiting after accidental ingestion of cow's milk products. There is no history of respiratory symptoms or severe systemic reactions. Previous attempts to introduce dairy in small amounts have consistently led to skin reactions. Her growth and development have otherwise been normal. Background Past medical history is notable for mild bronchiolitis at 4 months of age, requiring no hospital admission. Family history reveals paternal atopy with asthma and eczema, and maternal hayfever. There is no family history of severe food allergies. The patient lives at home with both parents and has no siblings. She is breastfed with occasional formula supplementation. Conclusion and Plan Based on the clinical history, examination findings, and investigations including positive skin prick tests and specific IgE to cow's milk, a diagnosis of IgE-mediated cow's milk protein allergy and atopic eczema has been made. The immediate management plan involves strict dietary avoidance of cow's milk protein for both the infant and the breastfeeding mother, supported by an amino acid-based formula prescription. We have referred Eleanor to the Paediatric Dietitian for ongoing dietary guidance and nutritional support. The parents have been advised on effective eczema management and recognising signs of allergic reactions. A follow-up appointment will be arranged in 6 months to assess the patient's progress and consider a supervised reintroduction of dairy. This letter summarises today's clinic appointment. It was created using voice recognition software. If you notice any inaccuracies or have questions, please contact me at 0123456789.