Allergy & Immunology Initial Consultation Template

HPI:  
The patient, a 35-year-old female, arrives with a primary complaint of ongoing nasal congestion and sneezing, persisting for the last three months. Symptoms worsen during the spring and are accompanied by itchy eyes and skin rashes. The patient mentions using over-the-counter antihistamines with partial relief.
Allergy History:  
The patient has a known allergy to peanuts, causing hives and breathing difficulties. She also reports a history of allergic reactions to bee stings.
Environmental History:  
The patient is employed as a school teacher and resides in a suburban area with her husband and two cats. She does not smoke but is often exposed to secondhand smoke at her workplace.
Current Medications:  
- Cetirizine 10 mg daily  
- Albuterol inhaler as needed  
Past Medical and Surgical History:  
- Asthma diagnosed at age 10  
- Appendectomy at age 20  
Physical Exam:  
- Nasal mucosa is swollen and pale  
- Skin examination shows erythematous patches on the forearms  
Laboratory and Test Results:  
- Positive skin prick test for grass pollen and dust mites  
- Normal spirometry results  
Assessment and Plan:  
- Allergic rhinitis (ICD-10: J30.9)  
- Asthma (ICD-10: J45.909)  
- Continue current antihistamine therapy  
- Start intranasal corticosteroid spray  
- Advise allergen avoidance strategies  
- Follow-up in 3 months for reassessment