Allergy and Immunology Consultation

Marcus Vance is 34 years old and identifies as male. The referral concerns recurrent pruritic wheals and suspected environmental allergies.

Atopic History

Presenting concerns and relevant history: Onset of daily pruritic wheals began 4 months ago without an identifiable dietary, medication, or contact trigger. Lesions resolve within 12 to 24 hours without residual bruising. Aggravating factors include hot showers, NSAID use, and tight clothing. There is no associated lip or tongue angioedema, dyspnea, or GI distress. He also reports perennial nasal congestion and rhinorrhea with a spring exacerbation, aggravated by dust exposure and grass cutting.

There is otherwise no reported food, medication, or venom allergy, and the patient denies symptoms consistent with atopic dermatitis, asthma, or allergic rhinitis.

Past Medical History

• Chronic spontaneous urticaria
• Perennial allergic rhinitis
• Essential hypertension
• Gastroesophageal reflux disease

Medications: perindopril (Coversyl®) 4 mg PO daily, pantoprazole (Pantoloc®) 40 mg PO daily, diphenhydramine (Benadryl®) 25 mg PO PRN

Social History

• Smoking: Lifetime non-smoker.
• Recreational substances: Occasional alcohol (2–3 drinks/week); denies cannabis or illicit drugs.
• Employment: Accountant (office-based).
• Drug coverage: Private coverage via Sun Life.
• Animals at home: One indoor domestic shorthair cat.

Family History

• Mother has seasonal allergic rhinitis and childhood asthma.
• Paternal aunt has rheumatoid arthritis; negative for immunodeficiency or pulmonary disease.
• Negative for hereditary or acquired angioedema.

Examination

• Pale, boggy inferior turbinates bilaterally; septum midline, no polyps.
• Clear to auscultation bilaterally, no wheezes or prolonged expiratory phase.
• Positive dermatographism; three scattered erythematous wheals on the volar forearms, no eczema.

Skin Prick Testing

Positive wheal and flare to Dermatophagoides pteronyssinus (6 mm), Dermatophagoides farinae (5 mm), cat pelt (5 mm), and Timothy grass (7 mm). Histamine control 6 mm, saline control 0 mm. Negative to dog, tree mix, ragweed, and moulds.

Spirometry

FEV1 3.85 L (98% predicted), FVC 4.70 L (100% predicted), FEV1/FVC ratio 0.82. Normal spirometry without airflow obstruction.

Impression and Plan

Marcus Vance is 34 years old, identifies as male, and has a history of chronic spontaneous urticaria and allergic rhinitis. Skin prick testing confirmed sensitization to house dust mites, cat dander, and grass pollen.

Urticaria

Chronic urticaria generally does not result from one particular exposure, so management focuses on controlling symptoms. Oral antihistamines are sufficient for many patients.

I provided written information about urticaria. I advised follow-up if the hives continue despite treatment or appear to be consistently associated with a recognisable trigger.

Prefer longer-acting antihistamines, including Reactine, Claritin, or Aerius, because they tend to last longer and be less sedating than Benadryl. I prescribed Reactine 10 mg daily to 20 mg BID and explained how to adjust the dose to obtain control with the lowest effective amount.

I have not scheduled follow-up, although I would be glad to review the patient within two years for this concern if the situation changes. I have scheduled follow-up for 6 months from now.

Thank you for sending this referral. Please contact me if any questions arise.

This documentation was prepared with assistance from an AI scribe. Consent was obtained before the session began.