Consultation for Food Allergies Template

Subjective:
- The patient, a 7-year-old boy, experiences repeated episodes of hives and stomach pain after eating peanuts. His mother notes these symptoms have been present for the last six months.
- Past medical history includes eczema diagnosed at age 3.
- Current medications include cetirizine 5mg daily for allergy management.
- Social history indicates the patient resides with his parents and is enrolled in primary school.
- Known allergies include peanuts and tree nuts.
Objective:
- Physical examination shows clear skin with no active 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: Allergy to peanuts and tree nuts.
- The allergy is of moderate severity, leading to significant dietary limitations and anxiety for the family.
Plan:
- Treatment plan involves strict avoidance of peanuts and tree nuts, and prescription of an epinephrine auto-injector for emergencies.
- Referral to a dietitian for nutritional guidance and meal planning.
- Patient education provided on identifying symptoms of an allergic reaction and correct use of the epinephrine auto-injector.
- Emergency action plan discussed, including when to use epinephrine and seek emergency medical attention.