PC1 SOAP Note 1

Katheryn Soto
ID: A.G. TOS: 1:15 pm

Age: 15 Insurance: Private PPO

DOS: 8/2/2017

CC: New pt referred from Dr. W (PCP) for percutaneous skin testing of food and seasonal allergens and

management of exercise induced asthma.

HPI: (Source: Pt mother): A.G. is a 15-year-old female who presents for skin testing for seasonal and

food allergies and management of exercise induced asthma. Pts reports symptoms of cough, SOB,

allergic rhinitis, and xeropthalmia that occur mainly in the Spring and Fall seasons. Generally,

symptoms have improved over time c age and managed well c OTC 2nd gen. antihistamines (Cetirizine

HCL) but this year have been less manageable. PMHx significant for anaphylactic reaction to tree nuts

which twice resulted in hospitalization at ages 9 and 11 (2011 and 2013; Loudon INOVA) which mother

requests to challenge during todays testing. Food allergy currently managed c avoidance of tree nuts

and potentially contaminated products. Pt carries Epipen for use in the event of accidental exposure. Pt

denies used of antihistamines in the past 5 days.

PMHx:

Surgeries - Appendectomy (2006)

Hospitalizations -Anaphylactic reaction to walnut ingestion (2011; Loudon INOVA);

Anaphylactic reaction to ingestion of potatoes contaminated c tree nuts (2013; Loudon INOVA)

Chronic conditions - Exercise induced asthma treated c Albuterol HFA PRN.

FMHx: Unknown; Pt adopted.

SHx: Never smoker. Lives r in a home c central AC and natural gas is used for heating and stove.

Bedrooms have carpet but the rest of the home is hardwood or tile. Bedding is not covered c
 2

hypoallergenic casings. No known mold in the home. Pt has two dogs who sleep inside and are allowed

in the bedroom.

ROS:

Head:: no HA, sinus pain or infection

Eyes: No vision changes; eyes are not red, itchy or watering

Nose: No sneezing, itchy or runny nose; moderate congestion

Throat: No cough, dysphagia, SOB, lymphadenopathy

Pulmonary: no chest tightness, recurrent pneumonia

Skin: no rashes

Immunological: significant for hay fever

Abdomen: no abdominal pain, BM changes

GU: no pain on urination

Medications: Allergies

Albuterol Sulf. HFA 90mcg Inhaler; 2 puff NKDA

PRN Food allergy to tree nuts (anaphylaxis)

Cetirizine HCL 10mg tab; 1 PO PRN Seasonal allergies to birch (allergic

Auvi-Q (epinephrine auto injector) 0.03mg rhinitis)

GA: WDWN

VS: W: 112lbs; H: 5'2"; BMI: 20.48; BP: 94/60; HR: 78/min; RR: 18/min;

PE:

H: Normocephalic, atraumatic; no masses, facial asymmetry, or swelling

E: PERRLA; conjunctiva is clear/pink

E: Clear auditory canal c some cerumen at border; TM visualized and in tact

 3

N: Boggy pink mucosa c hypertrophy of inferior nasal turbinates BL 2+; s discharge, polyps or

obstructions; septum midline and in tact

T: No post-nasal drainage or cervical lymphadenopathy

Pulm: No cough; Breathing unlabored s intercostal muscle retractions or accessory muscle use;

lungs CTA s WRR APL

Cardio: RRR s MRG; radial pulses symmetric and palpable BL

Skin: Good turgor; no lesions or rashes

Labs

Nitrous oxide expired gas determination (FENO) - 11ppb (normal <25)

Skin testing:

Histamine control: 3+ Saline control: 1+

Pt found hypersensitive to the following allergens:

2+ Foods (Almond, Walnut, Sesame Seed, Coconut, Peanut)

Trees (American Elm, Black Walnut pollen, Black Willow, Cottonwood

East, White Ash, Maple Box/Elder)

Grass (Bermuda, Orchard, Perennial Rye, Red Top, Timothy,

Dock/Sorrel Mix)

Environment (Dog, Cat, Hamster, Guinea pig, Horse, Mixed Fathers,

Mite Farinae, Mite Pterony)

Molds (Horm Hordeli, Phom Betae, Helminth-sporium)

Weeds (English Plantain, Ragweed Mix, Weed Mix)

3+ Foods (Hazelnut)

Trees (East Sycamore, American Beech, Hickory/Shagbark)

 4

Grass (Kentucky Blue/June, Meadow Fescue, Sweet Vernal, Grass Mix)

Environment (Rabbit)

4+ Trees (Red Oak, White Oak, River Birch, Tree Mix)

Spirometry: All measures WNL of expected values for pt. age, height, ethnicity and gender; No

signs of small or large airway obstruction.

Assessment

ICD-10

Code Description Diagnostic Rationale

Z91.010 Allergy to peanuts Although any food allergy has the potential to induce

anaphylaxis, life threatening reactions are most likely

Z91.018 Allergy to other foods with allergies to peanuts, tree nuts, fish, and shellfish.

These are also the least likely to resolve over time in

sensitized patients.1 Because qualitative scoring (0-4+)

of percutaneous testing is not standardized, the patients

history is positive for two anaphylactic reactions that

resulted in hospitalization due to tree nuts, and industry

trends to process these foods in the same machinery, I

felt that it was important to include all tree nuts and

peanuts in the patients diagnostic plan as foods to

avoid.2
 5

J30.1 Allergic rhinitis due to Allergic rhinitis is due to the overreaction of histamines

pollen to inhaled particles such as pollen and dander. Three

J30.9 codes were used as indicated per skin testing results.

Allergic rhinitis, unspecified

J30.81

Allergic rhinitis due to

animal (cat/dog) hair and

dander

R09.81 Nasal congestion Indicated due to hypertrophied and boggy inferior

turbinates on PE.

J45.990 Exercise induced Diagnosed by PCP and reported by patient.

bronchospasm

Plan

Continue to use Albuterol Sulf. HFA 90mcg Inhaler; 2 puff 10-15 min prior to strenuous activity

PRN for prevention of EIB. Rapid acting bronchodilator can be used for management of asthma

attack. If symptoms do not improve after initial use of rescue medication, call 911. Store

medication at room temperature. Follow up immediately if your symptoms do not improve or

worsen after using medication or if your inhaler seems to not be working as well as it used to and

you have to use it more frequently. Common side effects include rapid heartbeat, shakiness and or

trembling of extremities.

Continue to avoid peanuts, tree nuts, and foods that may contain these ingredients or that have

caused a reaction in the past. Will consider Immuno-cap component testing for tree nuts next year.
 6

Because of history of food allergies, it is best to introduce one new food at a time in small amounts

so that an allergic reaction can be recognized.

Carry 2 Auvi-Q rescue medications with you at all times in the event of accidental ingestion of

allergen. Use if symptoms of an anaphylactic reaction occur, which can include trouble breathing,

wheezing, hoarseness, hives, severe itching, skin rashes, fast heartbeat, feelings of anxiousness or

confusion, stomach pain, swelling of face, lips, mouth or tongue, or dizziness. Demonstration

performed in office using trainer. Medication should be administered into the muscle of the outer

thigh and can be injected through clothing if necessary. Tell your family members and others

where you keep your rescue medication in case you cannot administer it yourself in the event of an

emergency. Seek immediate medical attention after use. If Auvi-Q is accidentally injected into

any other part of the body, immediately seek emergency medical attention. Common side effects

of Auvi-Q include rapid heartbeat, sweating, shakiness, headache, pallor, excitability, weakness,

dizziness, nausea, breathing problems. Medication should be stored at room temperature. Avoid

exposure to extreme cold or heat. Unit should be replaced if the solution that can be seen in the

viewing window becomes cloudy, dark or pinkish in color. Forms for 2017-2018 school year

signed and returned to parent.

Continue Cetirizine HCL 10mg tab; 1 PO PRN for prevention of seasonal allergies.

Immunotherapy will be considered in the future as needed. Discussed with patient environmental

control to reduce aeroallergens, pet dander, dust mites and mold.

Letter sent to PCP. Plan for follow up in 12 months.

CPT

Code Description Coding Rationale

 7

99203 30 min new outpatient Extended HPI, ROS covering 2-9 systems, pertinent

FHx and SHx, and detailed PE.

95004 Percutaneous test with Coding for skin testing performed. This code Is a

allergenic extracts (Units: 59) single skin testing so the quantity of tests must be

indicated.

95012 Nitrous oxide expired gas Testing helps determine the level of inflammation

determination present in the lungs and is used in conjunction with

spirometry and patient history to determine level of

asthma control.

94375 Spirometry, including graphic Spirometry used to establish baseline measurements to

record, total and timed vital monitor patient for asthma control.

capacity, expiratory flow rate

measurements, +/- MVV

Katheryn Soto, PA-S

Katheryn Soto, PA-S

8/5/2017 9:00am
 8

Prescription:

Srinagesh Paluvoi M.D. & Nancy Twitchel F.N.P.

19415 Deerfield Ave # 210, Leesburg, VA 20176

(571) 642-1460

Name: A.G. DOB: --------

Address:1234 Pepper Park Place, Leesburg, VA, 20175 Date: 8/2/2017

Proair HFA, 90mcg

Sig: Inhale 1-2 puffs every 4-6h PRN 15 minutes before physical activity

Dispense: 1

Indication: Exercise induced bronchospasm

Brand medically necessary: No Refills: 1

Signature: Katheryn Soto, PA-S DEA #: VA 0000000

 9

References

1. Al-Muhsen S, Clarke AE, Kagan RS. Peanut allergy: an overview. Canadian Medical Association

Journal (CMAJ). 2003;168(10):1279-1285.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC154188/. Accessed August 5, 2017.

2. Joint Council of Allergy, Asthma and Immunology. Allergy diagnostic testing: an updated practice

parameter. Annals of Allergy, Asthma and Immunology . 2008;100(3):1-148.

https://www.aaaai.org/Aaaai/media/MediaLibrary/PDF%20Documents/Practice%20and%20Param

eters/allergydiagnostictesting.pdf. Accessed August 5, 2017.

3. Quillen DM, Feller DB. Diagnosing rhinitis: allergic vs nonalergic. American Family Physician.

2006;1(73):1582-1590. http://www.aafp.org/afp/2006/0501/p1583.html. Accessed August 5, 2017.