Frequent infections

Patient is 4-year-old boy who was brought in by his mother today to evaluate food allergies as well as eczema. He has a history of having vomiting and hives after ingesting peanut and now tree nuts as well as egg, peas, tomato and citrus. He has never been tested for allergies in the past and mom has avoided egg ever since he had a reaction of shortness of breath and required epinephrine over a year ago. He has not had any other episodes that have been so severe but he does seem to have vomiting episodes with certain foods as well as hives. He also has eczema that used to be worse when he was infant but is now very well controlled due to the fact that mom knows as well how to treat this as she has eczema herself and does a great job with skin hydration.

Patient does have some seasonal allergies of some nasal symptoms including nose rubbing, clear nasal drainage, nasal stuffiness, mouth breathing, and snoring. He did undergo a tonsillectomy due to severe congestion and snoring and it has resolved it some. Mom has not noticed any seasonal variations with this. She denies any problems with sinus infections or frequent ear infections, nasal polyps, aspirin-induced nasal symptoms or any nasal surgeries in the past. He does have frequent bad cold she tells during the cold season because he is at preschool.

He is a product of full-term normal delivery and is breastfed for six months. He did acquire pneumonia at six months old and was hospitalized in Connecticut for two days. He does frequently get pneumonia yearly now and requires antibiotics but no IV or hospitalizations. The last time he had pneumonia was one month ago.

He does not complain of any eye symptoms, any ear complaints or any wheezing or lung problems other than the history of pneumonia. Mom has not needed to use albuterol or any other maintenance therapies for asthma, although she has a nebulizer for any event of pneumonia. He has had a recent chest x-ray done in October at Capital City Family Medicine for this pneumonia.

He does have allergic eczema and has his whole life and today it is very mild. Mom states he gets this on his arm, legs, face and body. He has never been evaluated for allergies in the past.

ASSESSMENT:
1. Atopic dermatitis.
2. Food allergy to peanut, tree nuts and egg as well as shellfish.
3. Allergic rhinitis.
4. Frequent infections.

PLAN:
1. At this time, I provided mom with atopic eczema action plan. She does a very good job with treating his eczema and he is very well controlled today. I also provided her ointment of hydrocortisone 2.5% in times of needs of flare-ups. I also encouraged her to use Zyrtec one-half teaspoon as needed for itching.
2. I also prescribed Flonase one spray each nostril daily to reduce any allergic rhinitis or allergen loads.
3. We will pursue blood testing and ImmunoCAP RAST testing to egg, wheat, peanuts, almond, shrimp, crab, tomato, orange and peas to further verify food allergies. We also are going to do an immunodeficiency panel including CBC with differentials, immunoglobulin qualitative and quantitative, lymphocyte subset panel 1, anti-pneumococcal titer, anti-tetanus titer and anti-diphtheria titer to rule out any immunodeficiency.
4. He does have an EpiPen in case he interacts with these foods and it is up-to-date.
5. I will follow up in three to four weeks to go over lab results and see how patient is doing.

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