Allergy and Immunology Medical Transcription Sample Reports


HISTORY OF PRESENT ILLNESS:  The patient is here today for possible reaction to immunotherapy.  He is followed by Dr. Doe for allergic rhinitis and asthma and was last seen 5 months ago.  The patient is currently building on immunotherapy and yesterday received injections with oak/birch/maple 100 PNU 0.3 mL, grass and ragweed 100 BAU 0.3 mL, cat/dog 50 BAU 0.3 mL and mite and mold mix 100 units 0.3 mL.  The patient tells me after the immunotherapy, he went home and within hours felt some chest tightness.  The patient used his albuterol inhaler but the chest tightness got worse and he ended up taking his Symbicort 160/4.5 two puffs as well as some Claritin.  He continued to feel lethargic and out of breath.  He also had an itchy area on his left arm where he received the cat/dog injection.  He was able to go to sleep that night but woke twice due to wheezing and used his albuterol inhaler and went back to sleep.  When he woke up this morning, he was very tired and dizzy and could not catch his breath.  He used his albuterol inhaler once or twice this morning as well as his Symbicort and took a tablet of Zyrtec.  Then, around 9 or 9:30, when he was at work, he felt his tongue swelling.  During this time, he never felt he could breathe normally.  The albuterol inhaler did not have any benefit nor did the other medications he tried.  He tells me he had no rash, hives or vomiting.  He is not coughing.  He tells me he has not been sick this week.  No fever.  He has been off of his Symbicort since November because he felt his asthma is fine.  He has had no recent trouble with asthma.  No recent exposure to animals, dust or other allergens.  He is on no new medications.  He has no pets at home.  He continues to avoid turkey and chicken and has no new foods during this time.  He has a history of anxiety and panic attacks and does feel he is having one now.

MEDICATIONS:  Topamax for migraine headaches, Lexapro.

ALLERGIES:  NKDA.

PHYSICAL EXAMINATION:
GENERAL:  The patient is a healthy-appearing, well-nourished, well-developed (XX)-year-old male in no acute distress but does appear to be breathing heavy and very shaky and panicky.
VITAL SIGNS:  Height is 66 inches.  Weight is 132 pounds.  Blood pressure is 106/70.
HEENT:  Tympanic membranes are normal.  Throat is clear.  I did not appreciate any swelling of the tongue or angioedema.
NECK:  Supple without adenopathy.
LUNGS:  Completely clear.
HEART:  Regular rate and rhythm without murmur.

STUDIES:  The patient had spirometry when he was a little bit more relaxed and achieved an FEV1 of 3.1 liters or 88% of predicted, FEF25-75 is 118% of predicted.  At his last visit, his FEV1 had been a little bit higher at 3.22 liters or 95% of predicted.

IMPRESSION:
1.  The patient appears to be having some anxiety and panic now.  It is hard to say whether this started with some mild asthma symptoms as a result of his immunotherapy or if this is purely an anxiety issue.
2.  Allergic asthma.
3.  Allergic rhinitis.

RECOMMENDATIONS:
1.  We will cut back the dose of immunotherapy at next visit to oak/birch/maple 100 PNU at 0.2 mL, grass and ragweed 100 BAU at 0.2 mL, cat/dog 50 BAU at 0.2 mL and mite and mold mix 100 units at 0.2 mL.
2.  Restart Symbicort 160/4.5 two puffs twice daily.
3.  Zyrtec 10 mg daily for the next week and prior to immunotherapy.
4.  Albuterol 2 puffs every 4 hours as needed.
5.  The patient should follow up if symptoms do not clear in the next day or two.
6.  Routine followup with Dr. Doe in 6 months.


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REASON FOR VISIT:  The patient is here for skin testing to environmental allergens.

HISTORY OF PRESENT ILLNESS:  The patient is a long-standing patient of Dr. Doe and had received immunotherapy for the past several years. He had been getting injections for grass/ragweed/plantain, cat/dog/mold, dust mite and trees. He had been having some difficulty with local reactions and swelling to the tree injection. He has been using Advil before and after injections and ice, which helps. He gets injections every 4 weeks. He had an episode one time where his arms swelled significantly and he required oral prednisone.  He typically has allergy symptoms in February and March and November and December with rhinitis, congestion and itchy eyes. He has not obtained dust covers for his pillow and mattress. He has a carpet in his bedroom. He is not a smoker. 

MEDICATIONS:  Flonase and Clarinex prior to injections.

PHYSICAL EXAMINATION:  He is a healthy-appearing, well-nourished, well-developed (XX)-year-old male in no acute distress.

Skin testing via prick was positive to birch 2+, beech 2+, ash 0/1+, hickory 1+, mite DF 2+, mite DP 2+ and histamine 3+. Intradermal was positive to grass 3+, mugwort 1+, birch 3+, oak 4+, maple 3+, histamine was 3+.

IMPRESSION:  Seasonal and perennial allergic rhinitis.

RECOMMENDATIONS:
1.  Continue immunotherapy here with birch/oak/maple, mite DF/DP, grass/mugwort.  Dr. Doe will determine the dosage schedule.
2.  Continue Flonase 2 sprays per nostril daily during the spring and fall.
3.  Environmental control measures regarding dust and pollen.
4.  Follow up with Dr. Doe in 6 months.


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HISTORY OF PRESENT ILLNESS:  The patient is here for skin testing to food allergens and followup of her significant food allergies. She is followed by Dr. John Doe for food allergies to peanut, cashew, milk, egg, atopic dermatitis and a history of intolerance to soy formula. Prior to her last visit, the patient had been given peas for about the second time, and within minutes, she vomited and developed swelling and redness of her face and eyelids. She did not have any respiratory symptoms. She was brought to the emergency room and had been given Benadryl and oral prednisone. Today, she had sweet potato for the first time. She vomited afterwards and developed worsening eczema on her face in the perioral area and mildly on her arms. Her eczema continues to flare up around her mouth. They use desonide ointment and Elidel twice daily. She has seen Dr. Jane Doe and has a followup scheduled in October. 

PHYSICAL EXAMINATION:
GENERAL:  The patient is a healthy-appearing, well-nourished, well-developed (XX)-month-old infant in no acute distress.
VITAL SIGNS:  Weight is 17 pounds.
LUNGS:  Clear.
HEART:  Regular rate and rhythm without murmur.
SKIN:  Revealed pink erythematous scaling and dryness around her mouth and mildly over her arms. She did appear to be a little itchy. 

ALLERGEN SKIN TESTS:  Skin test revealed green peas 3+ but negative reactions to green bean, kidney bean, navy bean, sweet potato, yellow squash, soybean and lentil. Histamine was 4+ with negative saline. 

IMPRESSION: 
1.  Allergy to cashew, milk, peanut, egg and green peas. Worsening eczema after sweet potato, but no correlation on skin test. 
2.  Atopic dermatitis. 
3.  History of an anaphylactic reaction to peanut.
4.  Intolerance to soy formula with vomiting and constipation. 

RECOMMENDATIONS:
1.  Benadryl quarter teaspoon was given in the office to help with the itching. 
2.  Strict avoidance of tree nuts, peanuts, milk, egg, green pea and sweet potato.
3.  EpiPen Jr. as needed.
4.  Follow up with Dr. Jane Doe in October as planned. Skin care measures per Dr. Jane Doe.
5.  Followup as planned with Dr. John Doe.


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REFERRING PHYSICIAN:  John Doe, MD

CHIEF COMPLAINT:  Possible food allergies. 

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old boy seen in consultation at the request of Dr. Doe for a history over the last 8 months of abdominal pain, which is unexplained, and a more recent history of nasal congestion and sneezing. He has generally been in excellent health all his life. He began having periumbilical abdominal pain without vomiting or diarrhea about 8 months ago. Bowel pains would be noticed with anxiety or sometimes after or during eating. No specific food has been identified. There is no gassiness or bloating. The pain tends to be somewhat crampy in nature and occurs about 3 or 4 times a day. His mother states he has a daily bowel movement; although, it tends to be on the harder side. There are occasions when he has had some nausea. The sneezing and congestion has only been present for the last several months. He does have a prior history of wheezing with difficulty breathing, but he has no history of eczema. He has had ear infections, perhaps once or twice a year. He has no immediate reaction to furred animals such as their pet cat or dog. Evaluation includes negative Helicobacter antibody, negative tTG with a normal IgA of 88, normal liver and renal function, normal electrolytes, normal blood sugar, normal CBC, normal sedimentation rate of 3 and a negative strep culture. 

ENVIRONMENT:  They have a cat and a dog. They live in a 65-year-old home with forced hot water heat. They have wall-to-wall carpeting. There is air conditioning. They have no problems with mold. 

FAMILY HISTORY:  The patient's father has allergic rhinitis. His twin brother had tonsillectomy and adenoidectomy. 

PAST MEDICAL HISTORY:  He weighed 5 pounds 8 ounces at birth and was the first of twins. He was born by vaginal delivery and there were no problems as a newborn. He was nursed for 8 weeks. He had significant sleep apnea from enlarged tonsils and had tonsillectomy and adenoidectomy done when he was age 2. 

REVIEW OF SYSTEMS:  No history of chest pain, palpitations, heart murmur, jaundice, hepatitis, dysuria, hematuria, kidney or bladder problems, anemia, failure to thrive, heat or cold intolerance, joint pain, joint swelling, heartburn, history of seizures, migraines or depression. He has had no problems with hearing or vision. He may have had some mild reflux and colic as a newborn but was never treated. 

SOCIAL HISTORY:  He is in second grade. 

PHYSICAL EXAMINATION:
GENERAL:  He is a well-developed, well-nourished, alert, healthy-appearing, active (XX)-year-old boy in no acute distress.
VITAL SIGNS:  Blood pressure 94/54, weight 64 pounds and height 50-1/2 inches.
SKIN: Clear.
HEENT:  Tympanic membranes normal. Mild allergic shiners. Nose: There is 2 to 3+ pale edematous turbinates, clear discharge visible. Oropharynx: Benign.
NECK:  No lymphadenopathy or mass.
LUNGS:  Clear with tidal breathing with perhaps a few rhonchi with forced expiration.
HEART:  Regular rate and rhythm without murmur.
ABDOMEN:  Soft without organomegaly or mass. I could not feel any stool in his lower abdomen. 

ALLERGEN SKIN TESTS:  Testing for common potential food allergens was negative to 14 different major foods. Environmental testing showed strong reactions to DP mite 4+ and DF mite 4+, both with 25 mm wheals. All other environmentals were negative. 

IMPRESSION: 
1.  Abdominal pain for 8 months, intermittent and crampy, possibly related to constipation. There is no other evidence of any serious underlying medical problems based on testing done by Dr. Doe. It is possible this could be due to constipation. 
2.  Allergic rhinitis. He has significant dust mite allergy. 

RECOMMENDATIONS:
1.  Consider treatment for constipation with MiraLax. This will be deferred to Dr. Doe. 
2.  Consider GI evaluation if not improved. 
3.  Environmental controls for house dust mites were discussed and should be implemented. 
4.  Try Zyrtec or Claritin 1 tsp daily as needed, probably at bedtime for the allergic rhinitis. 
5.  Followup to be arranged as needed. 

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