Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
Chief Complaint: Briefly describe the patient’s main reason for this visit. This could include:
History of a recent Hymenoptera sting reaction (bee, wasp, yellow jacket, hornet, fire ant)
Concern about future sting reactions
Follow-up after allergy testing or initiation of allergy immunotherapy
History of Present Illness:
Date and location of the sting (if applicable)
Type of insect involved (if known)
Details of the sting reaction:
Local reaction (pain, swelling, redness, itching) – size and duration
Systemic reaction (anaphylaxis): difficulty breathing, wheezing, hives, nausea, vomiting, dizziness, fainting
Treatment received for the sting reaction (e.g., epinephrine, antihistamines)
Past Medical History:
History of previous Hymenoptera stings and reactions (local vs. systemic)
Atopic conditions (eczema, allergic rhinitis, asthma)
Medications (current and recent)
Family History:
History of allergies (any type) in first-degree relatives
History of anaphylaxis in first-degree relatives
Social History:
Occupation or hobbies that may increase exposure to stinging insects
Physical Examination:
General appearance (signs of allergic reaction if recent sting)
Skin exam (presence of hives or other allergic skin findings)
Vital signs (if applicable, for recent sting reaction)
Laboratory Tests:
Skin prick testing or blood tests (specific IgE) to identify Hymenoptera sensitivity – not always necessary but may be helpful for diagnosis and guiding treatment decisions
Imaging Studies:
Imaging studies are not typically used for Hymenoptera sting allergy.
Diagnosis:
Hymenoptera sting allergy (suspected or confirmed)
Severity of allergy (based on past reactions)
Atopic dermatitis/allergic rhinitis/asthma (if applicable)
Treatment Plan:
Avoidance of stings (protective clothing, insect repellent)
Anaphylaxis emergency plan and prescription of epinephrine auto-injector (EpiPen)
Antihistamines (for mild local reactions)
Allergy immunotherapy (allergy shots) – considered for patients with a history of moderate or severe allergic reactions, especially anaphylaxis
Prognosis:
Discuss the outlook based on the severity of the allergy and adherence to preventive measures and treatment plan.
Allergy immunotherapy can significantly reduce the risk of future severe reactions.
Patient Education:
Importance of avoiding stings and recognizing potential triggers
Proper use of epinephrine auto-injector and when to seek emergency care
Management of allergic skin reactions with antihistamines (if prescribed)
Benefits and risks of allergy immunotherapy (if offered)
Next Follow-up:
Schedule for the next appointment depends on the treatment plan.
Earlier follow-up if the patient experiences another sting reaction.
Regular follow-up for patients receiving allergy immunotherapy.
Note: This is a template and may need to be adapted based on the specific patient and their presentation. Terminology is provided in Chinese characters for reference.
Additional Considerations:
This template removes the redundant section, as imaging is not typically used for Hymenoptera sting allergy diagnosis.