Date:
Patient:
主诉 (zhǔ訴) (Chief Complaint): Briefly describe the patient’s main reason for presentation – presence of itchy, raised welts on the skin (hives).
History of Present Illness:
Onset and duration of hives
Severity and character of the hives (size, location, color)
Associated symptoms:
Itching (the most common symptom)
Angioedema (swelling of deeper skin layers, involving lips, eyelids, or genitals)
Abdominal pain, nausea, vomiting (less common)
Potential triggers for the hives (if identified):
Medications (e.g., antibiotics, aspirin, NSAIDs)
Food allergies (e.g., shellfish, peanuts)
Insect bites
Infections (less common)
Unknown cause (most frequent)
Past Medical History:
Allergies (medications, food, other)
Previous episodes of urticaria or angioedema
Underlying medical conditions (e.g., autoimmune disease, thyroid disease)
Family History:
Atopic conditions (allergic rhinitis, asthma, eczema) in family members
Physical Examination:
Vital signs (temperature, heart rate, blood pressure, respiratory rate) – May be normal unless angioedema involves the airway.
Skin examination:
Presence, size, location, and color of hives
Evidence of angioedema (if present)
Assessment:
Diagnose acute urticaria based on the clinical presentation (hives lasting less than 6 weeks).
Consider the severity of the urticaria (localized or widespread, presence of angioedema).
Identify potential triggers based on history and clinical presentation.
Plan:
Identify and avoid triggers: If possible, identify and avoid triggers to prevent further outbreaks.
Antihistamines: First-line treatment for symptom relief (itching and swelling).
Corticosteroids: May be added in severe cases or if antihistamines are ineffective.
Other medications: Leukotriene receptor antagonists (alternative for antihistamines) in some cases.
Adrenalin (epinephrine) auto-injector: May be prescribed for patients with severe allergic reactions or angioedema involving the airway.
Laboratory Tests (may be ordered depending on suspected cause):
Complete blood count (CBC) and differential
Thyroid function tests
Allergy testing (skin prick testing or specific IgE) – if a specific allergen is suspected
Consultations (if indicated):
Allergy/Immunology specialist (for complex cases or difficulty managing symptoms)
Progress Notes:
Document daily assessments including severity and location of hives, presence of angioedema, response to treatment, and any new symptoms.
Note any changes in medications or identification of potential triggers.
Update the plan as needed based on the patient’s progress.
Discharge Instructions:
Continue medications as prescribed.
Avoid identified triggers (if possible).
Instructions on using an epinephrine auto-injector (if prescribed).
Follow-up appointment to monitor progress and address any ongoing symptoms.
Disclaimer: This template is for informational purposes only and should not be used as a substitute for professional medical advice. Early diagnosis and treatment can improve the patient’s quality of life and prevent complications.