Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Follow-up for chronic urticaria, evaluation of symptoms, identification of triggers (if possible), and treatment plan.
SOAP
Subjective (S):
History of Present Illness:
Inquire about the following details of urticaria:
Duration of symptoms (chronic urticaria defined as lasting > 6 weeks)
Frequency and severity of wheals (raised, itchy skin lesions) and angioedema (deeper swelling)
Location and distribution of wheals
Triggers identified so far (e.g., foods, medications, physical stimuli)
Impact of symptoms on sleep, daily activities, and quality of life
Past Medical History:
Briefly summarize relevant past medical history, including:
Presence of atopic conditions (e.g., asthma, allergic rhinitis) – may be associated with chronic urticaria
Underlying autoimmune diseases (e.g., lupus) – can sometimes cause chronic urticaria
Thyroid function tests (TFTs) – abnormal thyroid function can contribute to urticaria
Previous medications – some medications can trigger urticaria
Social History:
Inquire about dietary habits, use of alcohol, smoking, and environmental exposures (e.g., latex, dust mites, pet dander).
Objective (O):
Vital Signs:
Record temperature, heart rate, blood pressure, and respiratory rate.
Skin Exam:
Describe the wheals (size, shape, color) and angioedema (location, severity).
Assessment (A):
Type of Chronic Urticaria:
Classify the type of chronic urticaria based on presence of identifiable triggers (e.g., inducible vs spontaneous).
Severity of Urticaria:
Assess the severity of urticaria based on frequency and duration of symptoms, and impact on quality of life.
Differential Diagnosis:
Consider other conditions that may mimic chronic urticaria (e.g., mastocytosis, bullous pemphigoid).
Plan (P):
Identify Triggers (if possible):
Discuss a potential food diary or elimination diet to identify food triggers.
Consider referral for allergy testing if appropriate.
Medications:
Develop a medication regimen based on the severity and type of chronic urticaria. Options may include:
H1-antihistamines (first-line therapy) to block histamine, a chemical that causes itching and wheal formation.
H2-antihistamines (may be added for severe cases)
Leukotriene receptor antagonists (for some patients)
Corticosteroids (short-term use for severe cases)
Management of Underlying Conditions (if present):
Address any underlying medical conditions that may be contributing to chronic urticaria, such as thyroid dysfunction or autoimmune diseases.
Patient Education:
Educate the patient about chronic urticaria, potential triggers, and the importance of treatment adherence.
Discuss strategies to avoid identified triggers.
Provide information on proper use of medications and potential side effects.
Explain the importance of seeking medical attention for worsening symptoms or angioedema involving the face, lips, tongue, or throat (potential signs of anaphylaxis).
Offer resources for support groups or educational materials on managing chronic urticaria.
Referral (if indicated):
Consider referral to a dermatologist or allergist for patients with severe or complex chronic urticaria, those with suspected underlying conditions, or those who fail to respond to initial treatment.
Follow-up:
Schedule follow-up visits to monitor symptom control, response to treatment, and assess for complications.
Define the frequency of follow-up based on disease severity, response to treatment, and presence of complications.