Food Allergy Consultation

Subjective: - The patient, a 7-year-old male, presents with recurrent episodes of hives and abdominal pain after consuming peanuts. The mother reports these symptoms have been occurring for the past six months. - Past medical history includes eczema diagnosed at age 3. - Current medications include cetirizine 5mg daily for allergy symptoms. - Social history reveals the patient lives with his parents and attends primary school. - Known allergies include peanuts and tree nuts. Objective: - Physical examination reveals clear skin with no current hives or rashes. - Vital signs: Temperature 98.6°F, Heart rate 90 bpm, Respiratory rate 20 breaths per minute, Blood pressure 100/60 mmHg. - Diagnostic tests: Skin prick test positive for peanuts and tree nuts. Assessment: - Diagnosis: Peanut and tree nut allergy. - The allergy is moderate in severity, causing significant dietary restrictions and anxiety for the family. Plan: - Treatment plan includes strict avoidance of peanuts and tree nuts, and prescription of an epinephrine auto-injector for emergency use. - Referral to a dietitian for nutritional counseling and meal planning. - Patient education provided on recognizing symptoms of an allergic reaction and proper use of the epinephrine auto-injector. - Emergency action plan discussed, including when to administer epinephrine and seek emergency medical care.