The following is an Assessment and Plan. The patient was last seen on 8/12/24, (so keep in mind the second mentioned Dx. This patient wasn't seen a year ago.) This date of service is 2/4/26. For coding sake, there are no new labs ordered or reviewed.
Please level this E/M based on the A/P below, and no new labs ordered/reviewed. Thank you!
1. Idiopathic cold induced urticaria with angioedema,
Remote Hx of idiopathic anaphylxis, poss 2/2 omalizumab, resolved and without recurrence with omalizumab (tolerating)
Patient is well-controlled on Xolair and would like to continue receiving injections in the clinic. He does note return of mild itching provoked by cold temperature when he is nearing his next dose, but denies any breakthrough hives.
PLAN:
- Minimize/avoid cold exposure, including strategies given exposures and travel
- Continue Xolair, every 4 weeks; patient tolerating well. May return to typical observational window of 30 minutes post-injection
Discussed with patient long-term therapy outlook
- Discussed cyproheptadine prn, however, given that he is well controlled and is using other non-sedating antihistamines, he wishes to avoid at this time. May reconsider in the future
- Continue Pepcid 20mg, twice a day
- Continue Allegra 180mg in the morning and Zyrtec 10mg at night
- Continue to carry Epi-Pen, reviewed signs/symptoms of anaphylaxis and use
2. Reaction to Xolair. 1st dose
Patient experienced an episode of syncope after his first injection ~1 year ago. Since then, he denies any further episodes of syncope, dizziness, or any other adverse effects. Since then, he has been observed post-injection for a longer period of time to ensure no adverse reaction. He feels comfortable moving forward with returning to typical observation length.
- Likely vasovagal reaction given lack of signs or symptoms of anaphylaxis or need for epinephrine
- Continue to carry Epi-Pen
Please level this E/M based on the A/P below, and no new labs ordered/reviewed. Thank you!
1. Idiopathic cold induced urticaria with angioedema,
Remote Hx of idiopathic anaphylxis, poss 2/2 omalizumab, resolved and without recurrence with omalizumab (tolerating)
Patient is well-controlled on Xolair and would like to continue receiving injections in the clinic. He does note return of mild itching provoked by cold temperature when he is nearing his next dose, but denies any breakthrough hives.
PLAN:
- Minimize/avoid cold exposure, including strategies given exposures and travel
- Continue Xolair, every 4 weeks; patient tolerating well. May return to typical observational window of 30 minutes post-injection
Discussed with patient long-term therapy outlook
- Discussed cyproheptadine prn, however, given that he is well controlled and is using other non-sedating antihistamines, he wishes to avoid at this time. May reconsider in the future
- Continue Pepcid 20mg, twice a day
- Continue Allegra 180mg in the morning and Zyrtec 10mg at night
- Continue to carry Epi-Pen, reviewed signs/symptoms of anaphylaxis and use
2. Reaction to Xolair. 1st dose
Patient experienced an episode of syncope after his first injection ~1 year ago. Since then, he denies any further episodes of syncope, dizziness, or any other adverse effects. Since then, he has been observed post-injection for a longer period of time to ensure no adverse reaction. He feels comfortable moving forward with returning to typical observation length.
- Likely vasovagal reaction given lack of signs or symptoms of anaphylaxis or need for epinephrine
- Continue to carry Epi-Pen