April 19, 2006
(Use SERVICE DATE.)
Julia A. Hallee, M.D.
1300 Crane Street
MC 5804
Menlo Park, CA 94025
RE: Xxxxxxxxx, Xxxxxx
MEDICAL RECORD #: XXXXXXXX
DATE OF BIRTH: 03/06/2003
(Do not include this heading unless dictated)
(BEGIN HERE IF IN CDFS.)Dear Dr. Hallee:
Dr. Robinson and I had the pleasure of seeing your patient, Xxxxxx, in our
Pediatric Pulmonary Clinic at Lucile Packard Children's Hospital today on
April 19, 2006. She is now a 3-year-old girl with history of significant
atopic asthma and allergic rhinitis, as well as previous history of
anaphylactic reaction to peanuts and significant aeroallergen sensitivity.
She was last seen in our clinic on January 18, 2006. Since that time, Xxxxxx
has been doing very well. Mom does not regularly give her prescribed
medications of Flonase, Xopenex, Pulmicort, or Zyrtec. Mom states that she
seemed to have an allergic reaction to cat where she had symptoms of
rhinorrhea, itchy red eyes and some mild wheezing at night. Mom gave her
Benadryl and Xopenex via nebulizer and she seemed to improve. She also had a
reaction to eating a walnut in which she had some facial edema, some coughing
and wheezing, and she was taken to the emergency room in which they gave her
Benadryl as well as some other unknown medication. Mom denies her having any
coughing or wheezing symptoms during the day and says that she rarely has a
runny nose or itchy eyes. She did have a runny nose a couple of days ago in
which she also had a low-grade fever. She thought it was probably a cold;
however, the next day she felt better and she had even given her some Flonase,
which she thought helped. She does have nightly coughing episodes which are
very mild and do not wake her up, and only last a couple of seconds. She also
coughs frequently in the morning, but only for a couple of seconds per mom.
REVIEW OF SYSTEMS: Mom states she continues to have eczema. She does not
have any symptoms of fever or upper respiratory infection at this time, no
vomiting or diarrhea. Her mom says that she is growing very well.
MEDICATIONS:
Flonase and Zyrtec as needed for allergic rhinitis.
ALLERGIES: Ceftriaxone, peanuts, milk, and eggs; however, she eats eggs
regularly and does not have any allergic symptoms.
PHYSICAL EXAM: Weight 11.4 kg, which is between the 3rd and 5th percentile.
Height 92.5 cm, which is between the 10th and 25th percentile and heart rate
of 103, respiratory rate 22, oxygen saturation 100%, temperature 35 tympanic.
GENERAL: She is an alert interactive toddler.
HEENT: Oropharynx is clear. Nares have some clear discharge. Nasal
turbinates are within normal limits. Right tympanic membrane clear, left
tympanic membrane blocked by cerumen.
NECK: Supple, no lymphadenopathy.
RESPIRATORY: Clear to auscultation bilaterally, no wheezes, rales, or
rhonchi.
CARDIOVASCULAR: There is a 2/6 systolic ejection murmur heard throughout the
precordium.
GI: Soft, nontender, nondistended, no hepatosplenomegaly. No masses.
EXTREMITIES: Warm and well perfused, no clubbing or edema.
IMPRESSION AND PLAN: In summary, Xxxxxx is now a 3-year-old girl with a
history of allergic rhinitis and atopic asthma which appears to be under good
control off medications. We do not see any need to follow her up in our
Pulmonary Clinic unless new problems arise. She should continue to followup
in the Allergy Clinic as needed. She can continue to take her Flonase and
Zyrtec as needed for allergic rhinitis.
Thank you very much for allowing us to follow Xxxxxx with you. If you have
any questions or concerns, please feel free to contact us 650-723-5191.
Sincerely,