Subjective:
Date of visit
Reason for visit (evaluation, reaction follow-up)
History of peanut allergy:
Age of first diagnosed reaction
Severity of previous reactions (anaphylaxis, mild allergic reaction)
Triggers of past reactions (ingestion, skin contact)
Current symptoms (if any)
Management strategies (epinephrine autoinjector, food avoidance)
Dietary restrictions and understanding of hidden peanut sources
Emotional impact of allergy (anxiety, fear)
Medication use (epinephrine autoinjector)
Past medical history (relevant conditions like eczema, asthma)
Family history (allergies)
Objective:
Vital signs (blood pressure, pulse) – if evaluating a recent reaction
Physical exam (focusing on normal findings, skin changes if relevant)
May include previous test results (skin prick test, blood test for specific IgE)
Assessment:
Confirmed peanut allergy
Severity of allergy (based on history and previous reactions)
Risk factors for future reactions (asthma, eczema)
Understanding of peanut avoidance and management strategies
Plan:
Education:
Reinforce peanut avoidance strategies (food labels, hidden sources)
Proper use of epinephrine autoinjector (practice with a trainer if needed)
Emergency action plan in case of accidental exposure
Medication management:
Ensure patient has a current epinephrine autoinjector and knows expiration date
Discuss proper storage and carrying of the autoinjector
Consider referral to an allergist (if complex case, need for oral immunotherapy)
Address emotional concerns (anxiety, fear)
Follow-up:
Schedule next appointment in X weeks/months for monitoring and education updates
Discuss need for repeat allergy testing (if indicated)
Note: This is a template and may need to be modified depending on the individual patient’s presentation and severity of allergy.
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of peanut allergy.