CHIEF COMPLAINT: The patient is here for evaluation of a possible allergic reaction to an insect sting. She is followed by Dr. John Doe for asthma and allergic rhinitis.
HISTORY OF PRESENT ILLNESS: The patient states she was hiking on Sunday around dusk. There were a lot of mosquitoes around, and she got some mosquito bites. She did not specifically feel a bite on her right knee but later noticed it was swollen and getting itchy. She is not having systemic symptoms. She denies hives, trouble breathing, vomiting, syncope. She tells me since Monday, she has been taking Benadryl 2 tablets every 4 to 6 hours and the itching has resolved. The swelling seems to be going down. However, she is worried about an anaphylactic reaction. She tells me she was stung by a bee about 15 years ago and had some foot swelling. She does not recall any systemic reactions or requiring a hospital visit for that; however, she recalled somebody giving her an EpiPen. It looked like Dr. John Doe had given her a Twinject to carry with her on the days that she received immunotherapy injection because she had a mild systemic reaction to immunotherapy in the past. She stopped immunotherapy in (XXXX), but did restart it in August, and is currently building with birch/maple/ash/hickory 10 PNU, mite/mold mix 10 units, grass/ragweed/mugwort 10 BAU, cat/dog 5 BAU every week. She no longer has a Twinject to carry.
MEDICATIONS: Symbicort 160/4.5 two puffs twice daily and Astelin as needed.
ALLERGIES: NKDA.
PHYSICAL EXAMINATION: She is a healthy-appearing, well-nourished, well-developed (XX)-year-old female, in no acute distress. Height is 68 inches. Weight is 130 pounds. Blood pressure is 126/66. She does appear somewhat nervous and used her Symbicort inhaler during the visit because she was feeling anxious. Her throat was clear. Her neck is supple without adenopathy. Lungs are completely clear. Heart: Regular rate and rhythm without murmur. Skin on her right knee, she has some mild pinkness and mild swelling, but no heat. It looks like an area of a bite, but I do not feel like there is any foreign body or sting here. There is no evidence of infection. Her knee only looks very mildly swollen, and it seems to be resolving. Her skin is, otherwise, clear and she has not had any other hives or swelling.
IMPRESSION:
1. Local reaction to an unknown insect sting or bite.
2. Asthma.
3. Allergic rhinitis.
RECOMMENDATIONS:
1. Discussed with the patient that she did not require testing or an epinephrine for a local reaction. Certainly, if it was starting to look infected and it developed increased swelling or other signs of infection, she should have it reevaluated. She may continue to take the Benadryl as needed, but it should clear up in the next few days.
2. I discussed with the patient that Symbicort is not a rescue inhaler. It is maintenance. She should continue to take 2 puffs twice daily and I gave her a prescription for ProAir 2 puffs every 4 hours to use as needed for any acute wheezing or trouble breathing.
3. She is building on immunotherapy now, and it looks like she had been given a Twinject to carry on the days of her injection and in the event of an anaphylactic reaction after she leaves. I gave her a refill for this as she no longer has one with her and explained how to use it.
4. She has a followup appointment with Dr. Doe.
