Hives Allergy Immunology SOAP Note Transcription Sample Report
SUBJECTIVE: The patient is a (XX)-year-old woman who we have been asked to see. Fourteen days ago, the patient awoke with itching. Soon thereafter, she was experiencing generalized hives. Since that time, she has had hives almost every day, except when she was on prednisone. On one occasion, she had the lower lip swelling. On one occasion, she woke up and sensed that she was having some difficulty breathing.
The evening before the onset of itching and hives, the patient ingested a restaurant meal consisting of red wine, an all green salad with oil and vinegar dressing, potato gnocchi with tomato sauce and antipasto. She had a bite of corned beef. Associated with the itching and hives has been a sense of acid reflux, which initially was intense and has been somewhat persistent.
Ten days ago, she started six-day prednisone taper of 60, 50, 40, 30, 20 and 10 daily respectively. When she got down to 20 mg, the itching and hives recurred.
For the past 20 years, the patient has experienced intermittent episodes of hives and swelling. Her last episode was two to three years ago. Early on, she was evaluated by Dr. John Doe and Dr. Jane Doe. Aspirin/salicylate allergy was presumed. She was told to avoid aspirin and certain foods containing salicylates. It was found subsequently that she was able to ingest some of the salicylate-containing foods with apparent impunity. She also avoids pepperoni pizza, which on one occasion seemed to provoke hives. She also seems to experience hives with upper respiratory infections.
At the onset, the patient was taking metoprolol 12.5 mg at bedtime. She has a history of PVCs. She was also taking simvastatin 20 mg daily, calcium with vitamin D, glucosamine/chondroitin sulfate and a multivitamin.
She has a history of sulfur-inducing hives and a questionable history of penicillin allergy. She denies a history of bee sting allergy. Her sister has seasonal allergic rhinitis. She denies a history of relatively frequent upper respiratory infections, pneumonia or childhood eczema. She had hay fever earlier in life but has been considerably better in recent years. Cat, rabbit and horse exposure will induce hay fever-like symptoms.
As a child, with upper respiratory infection, she would wheeze. In her teens, with the intense cat exposure, her chest would become tight. She has been treated for bronchitis in the past but not recently. She was a cigarette smoker for 10 years, up to 10 cigarettes a day. She stopped 20 plus years ago.
At home, there are no animals. She works at home.
OBJECTIVE: Well-developed, well-nourished woman in no acute distress. Blood pressure 124/72, pulse 82 and regular, height 66 inches, weight 195 pounds, pain score 6. The conjunctivae, tympanic membranes, auditory canals, nasal mucosa and septum were within normal limits. The oropharynx was clear. Neck examination revealed no palpable thyroid, lymph nodes or masses. The lungs were clear. Heart examination at the base was within normal limits. Her skin was very dermatographic with occasional urticarial lesion.
ASSESSMENT AND PLAN: The patient has chronic idiopathic urticaria. She is also likely experiencing increased signs and symptoms of gastroesophageal reflux disease due to histamine release. We have requested a hive panel, total IgE and RAST to several suspected foods as well as foods common to her diet.
We have started her on a regimen of 10 mg of Zyrtec and 300 mg of ranitidine every 12 hours taking hydroxyzine 25 mg t.i.d. p.r.n. She will stop all of the medications except for metoprolol and simvastatin. We plan to see her in 2 to 3 weeks. If she worsens on this regimen, we will give her a Medrol Dosepak. We asked her to call on a p.r.n. basis.
