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Allergy / Immunology Medical Transcription Transcribed Chart Note Sample

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old patient seen in consultation at the request of Dr. Doe for evaluation of a rash as well as treatment of rhinitis and eczema. The patient reports that she has a long-standing history of allergic rhinitis and eczema going back to when she was a child. The symptoms that she gets with rhinitis consist of sneezing, congestion, rhinorrhea, itchy-watery eyes, and stuffy nose. She also complains of headaches and fatigue. She reports the spring and the summer are particularly bad seasons for her, but she has symptoms in the fall as well. She usually wakes in the morning and sneezes 5-6 times. In the spring season, she has trouble with sneezing, congestion, itchy-watery eyes, as well as stuffiness and congestion. She denies any green nasal discharge, halitosis or foul-tasting postnasal drip. Her main triggers include grass pollen, moldy areas, damp basement, and moldy leaves. She also is bothered around cats. Cosmetics and perfumes bother her as well.

The patient has a long-standing history of eczema on her hands. She does uses latex gloves occasionally, but does report that these do not seem to bother her. She uses over-the-counter topical steroids off and on. She avoids washing her hands, but uses liquid soap. She has two children and changes a lot of diapers. She has to wash her hands when she does the dishes as well. She does not use a regular moisturizer other than Cetaphil. She currently is on no topical steroids.

The patient also came in with development of a red raised itchy rash that appeared on her arms this spring. She reports her arms became unbearably itchy for which she is having severe scratching. This also involved her upper chest area and her neck. Not involved any place where she had clothing contact. She notes it is worse when she would be out sweating or going for a walk. She reports it is worse during the middle day when she is outside, but occasionally would bother her in the middle of the night.

She saw her primary care doctor who gave her 10 days’ worth of prednisone. She did not have any increased sneezing during this time, but did report that her allergies and nose were in their usual state during that time of season.

She lives in a house that is about 5 years old. There is a dehumidifier in the house. No air-conditioner. No dogs, cats, or birds in the house. House was not particularly moldy or damp, had no recent rodent infestation or mold contamination. She has a cotton pillow.

PAST MEDICAL HISTORY: Significant for a heart murmur, also history of hay fever, and eczema. No history of heart, lung, liver or kidney disease. She has not had sinus surgery.

FAMILY HISTORY: Significant for asthma, eczema, and seasonal allergies.

ALLERGIES: The patient has food allergies. She states when she eats raw fruits, her lips get itchy. No trouble with regard to cooked or fresh fruit or vegetables. No insect reaction and no history of drug allergies. The patient reports no trouble with latex.

CURRENT MEDICATIONS: Birth control pills.

SOCIAL HISTORY: She did smoke in the past and stopped about 4 years ago.

PHYSICAL EXAMINATION:
GENERAL APPEARANCE: The patient is alert, in no apparent distress.
VITAL SIGNS: Height 62 inches. Weighs 115 pounds. Blood pressure 122/76.
HEENT: Normocephalic and atraumatic. Ears are clear. Nasal mucosa shows some clear watery rhinorrhea. There is quite a bit of congestion in her nose. No polyps seen. Septum appears midline. No green mucopurulent discharge. Conjunctivae clear. No rhinorrhea. Mouth is free of any lesions. No thrush. No exudate.
LUNGS: Clear. No wheeze or crackles heard.
SKIN: Eczematous lesions in between her fingers on both hands, wrist involved as well, with dry eczematous skin. Arms and elbows show well-hydrated skin with some healing lesions there. Skin is well hydrated. Otherwise, skin has no rash.

ENVIRONMENTAL ALLERGY TESTING: Showed a very high degree reactivity with 4+ reaction to dust mite, cat, grass, peach, birch, oak, ash, and ragweed. A 1+ reaction to hickory and maple. On intradermal testing, 4+ reaction to dog, 1+ reaction to mugwort, and no reactions to mold.

ASSESSMENT:
1. Severe seasonal and perennial allergic rhinitis.
2. Atopic dermatitis.
3. Oral allergy syndrome.
4. Contact dermatitis rash, unknown etiology.

PLAN:
1.  Skin testing to dust mite was positive. I discussed with the patient the nature of dust mite avoidance including encasings, keeping humidity low and washing sheets in hot water once a week. I reviewed the pamphlet from Mission Allergy. I recommended dust mite encasings from Mission Allergy and not from other sources, as the quality is highly variable among different suppliers. Handout given on dust mite avoidance. I discussed with the patient the signs and symptoms of allergic rhinitis including sneezing, congestion, and rhinorrhea as well as the complications of untreated rhinitis including chronic eustachian tube dysfunction, frequent sinus and ear infections, etc. Treatment options including medications and avoidance of immunotherapy injections were discussed. Handout was given from AAAAI.
2.  For her eczema, recommended daily washing of the skin on her hands, preferably some soaking in water. Recommended application of Elocon ointment once a day for the next 10 days to clear things up. In addition, I recommended evaluation with patch testing to see if any of the lotions she has been applying in the past are also bothering her skin. Recommend the use of an antihistamine, preferably Zyrtec. Recommended against the use of latex gloves. She will come back again in about two weeks for patch testing and review. For moisturizer, I recommended Vanicream. Follow up in about two weeks.

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