Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
New or follow-up for milk protein allergy (MPA)
(Specify) Symptoms suggestive of MPA reaction:
Gastrointestinal (GI) symptoms: Vomiting, diarrhea, abdominal pain, blood in stool (less common)
Skin symptoms: Eczema, hives, angioedema (swelling of lips, face, or throat)
Respiratory symptoms: Wheezing, coughing, shortness of breath (anaphylaxis in severe cases)
History of Present Illness:
Onset, duration, and severity of symptoms after milk or milk product ingestion.
Progression or improvement of symptoms since last visit.
Any previous confirmed or suspected allergic reactions to milk.
Specific milk products that trigger symptoms (e.g., milk, cheese, yogurt).
Past Medical History:
Age at onset of symptoms (MPA typically presents in infancy or early childhood).
Other allergic conditions (e.g., eczema, food allergies).
Atopic dermatitis (eczema) is a common comorbidity with MPA.
Family History:
Family history of allergies (parents or siblings with allergies increase risk).
Physical Exam:
Vital signs: Assess for signs of anaphylaxis (wheezing, hypotension).
Skin examination: Look for signs of eczema, hives, angioedema.
Gastrointestinal exam: Assess for abdominal distention or tenderness (if symptoms present).
Assessment:
Milk protein allergy (MPA): Based on clinical presentation (symptoms after milk ingestion) and may be supported by previous confirmation (skin prick test or blood test).
Severity of MPA reaction: Evaluate the severity based on type and intensity of symptoms (anaphylaxis is a medical emergency).
Differential diagnoses: Consider other causes of gastrointestinal or allergic symptoms (e.g., lactose intolerance, other food allergies).
Plan:
Dietary management: Strict avoidance of milk and all milk-containing products is essential. Review milk substitutes (e.g., soy milk, almond milk) and hidden sources of milk in processed foods.
Emergency preparedness: If the patient has a history of severe reactions, discuss an anaphylaxis emergency plan including an epinephrine auto-injector (EpiPen) and its use.
Follow-up: Schedule follow-up visits to monitor response to milk avoidance and discuss potential reintroduction challenges (in some cases, MPA can resolve in childhood).
Additional investigations (may be considered):
Skin prick test or blood test (specific IgE) to confirm MPA diagnosis (not always necessary if clinical presentation is clear).
Education:
Educate the patient and caregivers about MPA, symptoms, and the importance of strict milk avoidance.
Discuss food labeling and how to identify hidden sources of milk in processed foods.
Provide information on safe alternatives and resources for managing MPA.
Discuss the risk of anaphylaxis and the use of an EpiPen if prescribed.
Disclaimer: This template is for informational purposes only and should be adapted to the specific needs of each patient. Milk protein allergy can be a serious condition. Early diagnosis, strict milk avoidance, and proper education are crucial to prevent complications