Name: Patient 1 Date : 5/12/17 Time : 12:15

DOB: 3/13/1993 Sex: F

Subjective
CC:
Recurrent Hives all over body
HPI:
Patient states she is still having hives. They occur on random spots over her body. Patient
states the hives are very itchy. Patient states that she is only taking the Claritin once daily. She
states that the hives have decreased and there severity and frequency but she is still getting
them. Patient this time has taking care to eliminate all allergens from her household. She has
not changed laundry soaps, is not using any new perfumes, body washes or lotions. Patient
denies new meds The patient denies cough, chest pain, dyspnea, wheezing or hemoptysis.
Medications:
− EPIPEN 0.3 MG/0.3ML SOAJ INJECT 0.3 ML INTRAMUSCULARLY ONCE AS NEEDED FOR
ALLERGIC REACTION FOR 1 DOSE 2 Each 1
− Ibuprofen (MOTRIN PO) take by mouth.
− loratadine (CLARITIN) 10 MG tablet take 1 Tab by mouth Daily. for allergies 30 Tab 3
− MICROGESTIN FE 1/20 1-20 MG-MCG per tablet TAKE ONE TABLET BY MOUTH ONCE
DAILY 28 Tab 10
− omeprazole (PRILOSEC OTC) 20 MG tablet take 1 Tab by mouth Every morning (before
breakfast). for acid reduction 90 Tab 3
− triamcinolone acetonide (KENALOG) 0.1 % cream apply 1 Application to skin 2 times daily.
apply thin layer to affected area 2 times daily for rash 30 g 0
− predniSONE (DELTASONE) 10 MG tablet Take 3 x 3 days, 2 x 3 days, 1 x 3 days. 18 Tab 0
− ranitidine (ZANTAC) 150 MG capsule take 1 Cap by mouth 2 times daily. 60 Cap 3

Allergies:
− Bee stings
− Environmental

PMI
− Encounter for supervision of normal pregnancy in third trimester 05/06/2016
− Cystic fibrosis carrier 03/09/2016
− GERD (gastroesophageal reflux disease)
− Mild intermittent asthma
FH:
Mother: Living, healthy no known medical conditions
Father: Living, HTN
SH:
Tobacco: denies former or current tobacco use
ETOH: Occasional for special events
Elicit drugs: none
ROS

REVIEW OF SYSTEMS: CONSTITUTIONAL: Denies: fever, chills, diaphoresis, weakness, fatigue,

weight loss, weight gain
ALLERGIES: Denies: urticaria, hay fever, angioedema
EYES: Denies: blurry vision, decreased vision, loss of vision, eye pain, diplopia, photophobia,
discharge
ENT: Denies: sore throat, nasal congestion, nasal discharge, epistaxis, tinnitus, hearing loss
CARDIOVASCULAR: Denies: chest pain, dyspnea on exertion, orthopnea, paroxysmal
nocturnal dyspnea, edema, palpitations
RESPIRATORY: Denies: cough, hemoptysis, shortness of breath, pleuritic chest pain, wheezing
ENDOCRINE: Denies: polydipsia/polyuria, palpitations, skin changes, temperature intolerance,
unexpected weight changes
HEME-LYMPH: Denies: swollen lymph nodes, bleeding, bruising
GI: Denies: abdominal pain, flank pain, nausea, vomiting, diarrhea, constipation, black stool,
blood in stool
GU: Denies: Denies: dysuria, frequency/urgency, hematuria, genital discharge
NEURO: Denies: dizzy/vertigo, headache, focal weakness, numbness/tingling, speech
problems, loss of consciousness, confusion, memory loss
MUSCULOSKELETAL: Denies: muscle pain, muscle weakness
SKIN: Patient complains of red raised rash, today appears on BL outer ankles, back, and right
forearm. She says the spots are better than last time she was seen, approximately one month
ago. They are itchy but not painful.
PSYCH: Denies: anxiety, depression, physical abuse, sexual abuse
Objective

Wt: 174 lb Temp: 97.3 Pulse: 107

Ht: 5 ft 1 in BP: 116/82 Resp: 16

Physical Exam

Eye exam is normal - PERLA, EOMI, fundi normal, corneas normal, no foreign bodies, visual
acuity normal both eyes, no periorbital cellulitis.
Ear exam - bilateral normal, TM intact without perforation or effusion, external canal normal.
No significant ceruminosis noted. Conjunctiva pink
Nasal exam; septum midline, no deformities, nares patent, normal mucosa without swelling,
no polyps, no bleeding.
Oropharyngeal exam - mucous membranes moist, pharynx normal without lesions.
The neck is supple and free of adenopathy or masses, the thyroid is normal without
enlargement or nodules, bilateral carotid bruits
CVS exam: normal rate, regular rhythm, normal S1, S2, no murmurs, rubs, clicks or gallops.
Chest: clear to auscultation, no wheezes, rales or rhonchi, symmetric air entry.
The abdomen is soft without tenderness, guarding, mass, rebound or organomegaly. Bowel
sounds are normal. No CVA tenderness or inguinal adenopathy noted. Genital rectal exam
decline.
Extremities: peripheral pulses normal, no pedal edema, no clubbing or cyanosis,
monofilament sensory exam is normal in both feet.
Integumentary- scattered red, wheals seen on ankles and right forearm as well as stomach
and back. Papules slightly raised and have well defined boarders.
Neuro: Cranial nerves and fundi are normal. PERLA. EOM's intact. No papilledema. Neck
supple. No bruits. Normal deep tendon reflexes
Assessment

Differential Diagnosis: Urticaria vs. Eczema

Diagnosis: Chronic Idiopathic Urticaria

Plan

Plan:

1. Chronic Idiopathic Urticaria – unsuccessful with us of Claritin and Prednisone, Zantac

2. Increase Claritin frequency to 10mg BID, restart Zantac 150mg BID and add Benadryl
50mg at night
3. Make referral to Michigan ENT and Allergy Specialist

References:
Dunphy, L.M, Winland-Brown, J.E., Porter, B.O., & Thomas, D.J. (2015). Primary Care: The Art of

Science of Advanced Practice Nursing (4th ed.) Philadelphia, PA: F.A. Davis Company

Hives (Chronic Uticaria) (2016). In Patient Info. Retrieved June 14, 2017, from

https://patient.info/health/hives-chronic-urticaria

Urticaria (2017). In American Osteopathic College of Dermatology. Retrieved June 14, 2017,

from http://www.aocd.org/?page=Urticaria