Allergy and Immunology Inpatient Consultation Note

Date/Time of Consult: [Consult request date and time]

Date/Time of Note: [Note completion date and time]

Patient: [Name] | [MRN] | [DOB] | [Age] | [Sex]

Location: [Unit/Room]

Consultant: [Allergy/Immunology consultant name and role]

Requesting Service/Clinician: [Service/Clinician name]

Reason for Consult

Consult requested by [requesting service/clinician] for [specific question(s)]. [Urgency or time-sensitive decision if applicable]

Brief Summary

[One to three sentence clinical context: patient age, key comorbidities, reason for hospitalization, and the allergic/immunologic issue prompting consultation]

History of Present Illness

[Narrative summary of current hospitalization context and the index event/condition prompting consultation] (Attribute sources explicitly: "per patient," "per chart review," "per nursing documentation." Include relevant prior similar episodes only if applicable.)

(For acute reactions such as anaphylaxis, angioedema, or suspected drug reactions, include a timestamped timeline as below. For non-acute consultations such as immune deficiency evaluation, omit the timeline.)

• Timeline (acute events only):
• [Date/Time] — [Baseline status and exposures in prior 24–72 hours]
• [Date/Time] — [Trigger exposure: drug name, dose, route; food; contrast; venom; other]
• [Latency from exposure to symptom onset]
• [Organ systems involved: skin/mucosal, respiratory, cardiovascular, GI]
• [Objective findings and vitals during event]
• [Treatments administered: agent, dose, route, timing, and response]
• [Recurrence or biphasic symptoms, if any]

(For immune deficiency consultations, emphasize infection pattern: sites, frequency, severity, organisms; secondary immunodeficiency risk factors; vaccination history and responses.)

Past Allergy/Immunology History

(Include only details relevant to the current consult.)

• [Prior anaphylaxis episodes and triggers]
• [Chronic urticaria/angioedema history and control]
• [Asthma control status]
• [Atopic conditions]
• [Food/venom/latex allergies; prior testing or challenges]
• [Drug reactions and prior testing performed]
• [Immunotherapy or biologic therapy history]

Relevant Medical History

• [Comorbidities influencing diagnosis or management]
• [Relevant procedures or surgeries]

Medications

Home medications: [Relevant pre-admission medications with doses if pertinent]

Inpatient medications: [Current inpatient medications with start dates; highlight agents temporally linked to the event under evaluation]

Current Allergy/Adverse Reaction List

• [Substance] — [Reaction phenotype], [Severity], [Timing if known], [Verification status: patient-reported / documented / test-confirmed]. [Tolerance of related agents if relevant]
• (Repeat per documented allergy. Note discrepancies between EHR and patient history if present.)

Family and Social History

(Include only if relevant to the consult. If unobtainable, state reason.)

• [Family history of angioedema/HAE, immunodeficiency, mast cell disorders, severe drug reactions]
• [Occupational or environmental exposures pertinent to triggers]

Review of Systems

(Focused to the consult question. Include key positives and discriminating negatives. Expand if systemic drug reaction suspected.)

• [Skin/mucosal: urticaria, flushing, angioedema, mucosal involvement]
• [Respiratory: wheeze, stridor, dyspnea]
• [Cardiovascular: syncope, hypotension, palpitations]
• [GI: nausea, vomiting, diarrhea, abdominal pain]
• [Systemic: fever, lymphadenopathy, malaise]

Physical Examination

Vitals: [Current vital signs with time]

• General: [Appearance, distress level]
• Airway: [Lips, tongue, uvula, voice quality, stridor]
• Skin: [Rash morphology, distribution, mucosal involvement, skin pain, edema]
• Respiratory: [Wheeze, work of breathing, breath sounds]
• Cardiovascular: [Rate/rhythm, perfusion status]
• Lymphatic: [Lymphadenopathy if systemic reaction suspected]
• Other: [Additional focused findings as relevant]

(If exam is limited, state reason.)

Data Reviewed

(Include only data used for clinical decision-making.)

• Vitals trends: [Trend summary with time anchors relevant to event]
• Laboratory data: [Key labs with values and collection times]
• Specialty labs: [Tryptase, complement studies, immunoglobulins, specific IgE] (Include collection time and interpretive context.)
• Imaging: [Pertinent imaging and findings]
• Microbiology: [Cultures/PCR/serologies relevant to differential]

Assessment

(Numbered problem list ordered by acuity. Use phenotype-based descriptors. Distinguish confirmed vs suspected and immediate vs delayed reactions. State certainty level for drug causality.)

1. [Problem 1]: [Working diagnosis/phenotype]

   • Supporting evidence: [Key findings]
   • Against/alternatives: [Alternative diagnoses considered]
   • Clinical risk: [Airway risk, recurrence risk, medication safety implications]

2. [Problem 2]: [Diagnosis/phenotype]

   • Supporting evidence: [Key findings]
   • Against/alternatives: [Alternative diagnoses considered]
   • Clinical risk: [Risk assessment]

Recommendations

(Numbered to correspond with Assessment problems. Be explicit and actionable.)

1. [Problem 1]:

   • Immediate actions: [Monitoring level, rescue medications, airway precautions, additional consults]
   • Medication recommendations: [Drugs to start/stop/avoid with rationale; safe alternatives; cross-reactivity guidance]
   • Diagnostic plan: [Tests to order now vs defer to outpatient; timing requirements]
   • Discharge planning:
     • Prescriptions: [e.g., epinephrine auto-injector with dosing]
     • Patient education: [Avoidance, symptom recognition, epinephrine use]
     • Recommended EHR allergy list update: [Substance, reaction phenotype, severity, certainty level]
     • Discharge summary language: [Suggested statement]
     • Follow-up: [Timeline and location]
   • Contingencies: [If symptoms recur; if culprit drug urgently required]

2. [Problem 2]:

   • Immediate actions: [Details]
   • Medication recommendations: [Details]
   • Diagnostic plan: [Details]
   • Discharge planning: [Details]
   • Contingencies: [Details]

Patient Counseling

(Include only when counseling materially affects management.)

[Summary of counseling provided regarding avoidance, epinephrine use, emergency response, and plans for future testing. Patient/family understanding and agreement with plan.] (Note interpreter use if applicable.)

Communication

Recommendations discussed with [team/person] at [time] via [in-person / phone / pager / secure message]. [Recommendations implemented / pending].

(Omit sections not relevant to the specific consult. If information is relevant but unavailable, include placeholder explaining why. For acute reactions, the timestamped HPI timeline is essential. The recommended EHR allergy entry in Recommendations is a required deliverable.)