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Allergy and Immunology Medical Transcription SOAP Note Sample

SUBJECTIVE:  The patient is a (XX)-year-old female who has been previously evaluated and treated by Dr. Doe. His initial note stated that she was skin tested with multiple positive tests. Subsequently, she became pregnant and was lost to followup. The patient has year-round allergic rhinitis and to some extent conjunctivitis, which is exacerbated in the spring and to a lesser extent in the late summer. At times in the spring and late summer, she will wheeze. She may also wheeze when she has an upper respiratory infection. With the wheezing, her chest may be tight. She claims to have a history of 3 to 4 upper respiratory infections a year. She also has a history of recurrent ear infections, primarily on the left, not in the past 3 years. Her sense of smell appears to be intact. She denies history of sinusitis, pneumonia or cigarette smoking. She claims to have had bronchitis on 3 different occasions; the last episode was several years ago. In the spring of (XXXX), she had 2 episodes of hives on her anterior neck and chest.

The patient also has multiple food allergies, primarily to apples, plums, strawberries, peaches, pears, cherries, melons, pineapples, kiwi, and bananas, primarily with itchy throat, etc. Nuts such as walnuts and almonds provoke an itchy throat as well. Her sister has allergic rhinitis. Her mother has allergic conjunctivitis. For the past 4 years, she has lived in a 5-year-old house, central air conditioning, regular pillow and mattress, wall-to-wall carpeting. The patient has a 15-month-old daughter who is taken care of by the patient's mother during the day. There is no animal exposure. For the past 6 years, she has worked in an office with central air conditioning.

MEDICATIONS:  Present medications include Claritin, which does not seem to help. She has hydrocortisone cream for eczema. She uses Cetaphil cleansing lotion. She is not aware of any allergies to medications.

GENERAL:  The patient is a well-developed, well-nourished female, in no acute distress.
VITAL SIGNS:  Blood pressure 132/84. Pulse 78 and regular.  Height 68 inches. Weight 142 pounds.  Pain score 0.
HEENT:  Conjunctivae within normal limits.  The left tympanic membrane was distorted and scarred with some centralized erythema.  The right tympanic membrane and both auditory canals were within normal limits.  The nasal mucosa was boggy. Nasal septum was within normal limits.  The oropharynx was clear.
NECK:  Examination revealed soft movable anterior nodes. There were no palpable thyroid masses.
LUNGS:  Clear.
HEART:  Examination at the base was within normal limits.
SKIN:  Generally dry. There were scattered fine maculopapular lesions on her arms with some excoriations.

1.  The patient has perennial and seasonal allergic rhinitis with conjunctivitis. She also has mixed asthma, primarily extrinsic. She has food allergies to the aforementioned foods. The patient will avoid fruits and all nuts. The patient will carry Benadryl. I also gave her an EpiPen to use if she has an allergic reaction that was associated with difficulty breathing or lightheadedness.
2.  She also has atopic dermatitis. I gave her some Lidex E to be applied b.i.d. p.r.n. to erythematous dermatitis.  She has mite covers on her bedding.  I prescribed Allegra D 24 hours 1 p.o. daily p.r.n. and Patanol drops 1 each eye b.i.d. p.r.n. I also gave her a prescription for albuterol 2 inhalations q.i.d. p.r.n. wheezing and tightness in her chest. I told her that if she started to use this regularly, more than once or twice a day, she is to call me.

I plan to see her in June for followup evaluation of her regular allergies. I plan to bring her in earlier for local anesthetic testing. In the meanwhile, I have ordered a RAST to latex, bananas, kiwi, cherries, melons, avocado, and chestnut. The patient’s spirometry ordered and reviewed by me today was within normal limits.

Allergy / Immunology Sample Report

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