Wiki Would you code an E/M with this test?

renifejn

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Patient returns for food challenge to egg

Date of initial reaction--12 mos of age

Manifestation of initial reaction--hives and rash around mouth with scrambled eggs

Date of most recent exposure--none since initial

Treatment given--N/A

Has child had any recent pruritis, rash, URI, resp or GI problems--No

PE
General--WDWN in NAD
Head-Normal
Ears-Normal
Eyes-PERRLA, EOMI
Nose-normal
Throat-Normal
Neck-Normal
Chest/Lungs-Normal
CV-Normal
Abdomen-Normal
GU-Not performed
Extremities--normal
Neuro--Normal
Skin--Normal

After obtaining informed consent, an ingestion challenge was performed.
Forms of food that pt ingested-french toast
Amount of food--1 egg

An adverse reaction did not occur

Assessment
negative food challenge test

Plan
Monitor for evidence of delayed reaction today. And if there is none, the child may eat egg ad lib.

Counseling was performed by me regarding food allergen aviodance, dietary changes, home treatment with meds and possible manifestations of delayed reactions.
 
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