NEW SOAP Template - Empathia Revised

Chief Complaint

Medical Note Template -- Allergy and Immunology Assessment

Introduction

Dear [Dr./Mr./Ms.] [referring practitioner last name], Thank you for referring this pleasant [age](if the age is less than 3 years-old, write in months-old instead of years-old) [sex] for allergy/immunology assessment. [Pronoun] was seen [in person/via telehealth].

History of Presenting Illness

For each problem, provide a very detailed narrative history including onset, duration, character, and associated symptoms, past investigations, and previous physicians seen or treatments tried. Include details, quotes, and examples. No new diagnosis should be made in this section, and it should not repeat information provided in the Impression and Plan section. If the problem is Rhinitis, include the following: [describe rhinitis symptoms including time since onset of symptoms, perennial or seasonal pattern, triggers reported by the patient, medications tried and their degree of benefit if relevant, prior otolaryngologist findings on endoscopy if any. [do not include name of specific diagnoses unless explicitly stated, such as “allergic rhinitis”]] If the problem is Asthma, include the following: [include the time of diagnosis, asthma symptoms such as dyspnea, chest tightness, wheezing and coughing, most recent pulmonary function test or spirometry and its results if available, presence of nocturnal symptoms or functional limitations, number of exacerbations in the past year, whether emergency room visit was needed, whether oral steroids was needed for asthma exacerbation, current medications available for asthma, frequency of their use, and whether they are followed by a respirologist, if relevant] If the problem is Adverse Food Reactions, include the following: (Peanut, almond, hazelnut, cashew/pistachio, walnut/pecan are separate families of foods and should not be combined.) - Specific food. - Age of patient at time of reaction (age can be in months if provided). - Size of ingested serving, and specific food ingested. - Symptoms after ingestion, including symptom timing and duration. - Whether patient proceeded to hospital, and any additional symptoms during transport. - Symptoms upon arrival at the Emergency Department (ED). - Specific medicine(s) given, who it was given by, location where it was administered (home, hospital). - Symptoms that improved or resolved, including timing of improvement or resolve. - Whether symptoms have reoccurred. - Whether any specific testing was completed previously, including specific test results. - Any accidental or subsequent same food exposures since original; include the form of exposure and size of exposure. The specific allergenic food may be included as an ingredient in another food (e.g., egg in cookie dough). Include symptoms or lack of symptoms which may be a contraindication to the presence of continued allergy to this food or ingredient. - Any additional treatments prescribed previously (e.g., food ladder). - Whether patient has an epinephrine auto-injector, include brand, type, and whether they have training devices available. Conclude the problem by listing the common allergenic foods that have been tolerated and ones that have not yet been tried. (Common allergenic foods include egg, cow's dairy, wheat, soy, sesame, peanut, almond, hazelnut, cashew or pistachio, walnut or pecan, fish, shellfish.) If the problem is Eczema or Atopic Dermatitis, include the following: [include time of diagnosis, current distribution of affected areas on the body, frequency of flares, moisturizer name and frequency of application, medications tried and their degree of benefit if relevant, current medication plan, prior skin infections, prior dermatologist evaluations] If the problem is Rash or Urticaria, include the following: - time of first onset of the rash. - frequency of episodes since initial presentation of the rash. - description of the rash, including visual features, distribution on the body, how long each spot lasts for, residual findings on the skin after the rash resolves. - associated symptoms such as angioedema. - Medications used, dose if specified, and whether there is improvement. - Prior dermatologist evaluations and whether a biopsy has been done. For all other problems mentioned, write is as instructed below: [For each problem, provide a very detailed narrative history including onset, duration, character, and associated symptoms, past investigations, and previous physicians seen or treatments tried. Include details, quotes, and examples. No new diagnosis should be made in this section, and it should not repeat information provided in the Impression and Plan section.] Output as a list of each problem with a detailed history in sentence format, and with a new line separating each problem: 1. [Problem 1]: [detailed history] 2. [Problem 2]: [detailed history] If the problem is Food Allergy, separate each type of food further in a lettered sub-list under the Food Allergy numbered list item: 1. Food Allergy: a) [Specific food]: [detailed history]]

Adverse Drug Reactions

[[There are no known allergies to medications./The patient reports the following adverse reactions with medications:] (group in a numerical list based on the medicine type) 1. [Penicillin based antibiotics] [Include medicine, describe the reaction and how long ago the reaction occurred] 2. [Non-steroidal anti-inflammatory medication including aspirin, naproxen or ibuprofen] [Include medicine, describe the reaction and how long ago the reaction occurred] 3. [Sulfa based antibiotics] [Include medicine, describe the reaction and how long ago the reaction occurred] 4. [Other] [Include medicine, describe the reaction and how long ago the reaction occurred] [If patient is over 18 years old include any contact allergies] 1. [Latex] [Describe the substance, the reaction, and how long ago the reaction occurred] 2. [Other] [Describe the substance, the reaction, and how long ago the reaction occurred]

Stinging Insect Reactions

[None reported. (if no insect allergy reported)]

Other Allergy Concerns

[Narrate history of other allergic complaints not mentioned above (if applicable) (do not include skin testing results from later in the encounter)] (bullet point format)

Past Medical History

[Include all significant medical conditions (do not include surgeries)] (bullet point format) (list only the diagnosis and minimize details) [If no other medical history mentioned, state: healthy]

Past Surgical History

1. [Surgical Procedure and Year if relevant] 2. [Surgical Procedure and Year if relevant]

Medications

[Include the name, dosage, frequency, and route of administration for all current medications, including over-the-counter drugs and supplements.] (bullet point format)

Family History

[Include any relevant family history of allergic and atopic conditions, such as eczema, asthma, food allergy and environmental allergy.] No family history of atopy.

Social and Environmental History

[Patient's occupation, smoking status, alcohol use, drug use, diet, exercise, living situation, and any relevant social factors, including occupational exposures and pets at home.]

Immunizations

Physical Examination

[If examination is performed, include only physical exam findings stated by the physician in the transcript. Do not include skin testing findings. Do not include examination findings by other physicians in the past] Head and Neck: oropharynx was clear [include other head, neck, ear, nose and throat physical exam findings] Chest: no wheezing [include other lung findings] Skin: no rash [include any skin findings but do not report skin testing results] [If no examination is performed due to telehealth visit, state: Deferred due to the nature of telehealth visit]

Skin Testing

[Inhalants: Positive reaction to: [dust mite/cat/dog/tree pollen/grass pollen/weed pollen/mold] (include wheal size in mm if stated) Negative reaction to: [dust mite/cat/dog/tree pollen/grass pollen/weed pollen/mold] (list all by default if not specified)] [Foods: Positive reaction to: [list positive food allergen test results] (include wheal size in mm if stated) Negative reaction to: [list negative food allergen test results]] Histamine control was [positive/negative]. [Skin testing was complicated by dermatographism. (include only if explicitly stated)]

Investigations

[Bloodwork: (list each blood test) [Include any blood tests, by first writing the date, then followed by the test results]] [Imaging: (list each x-ray, CT scan, MRI, ultrasound or other imaging test) [Include any imaging tests, by first writing the date, then followed by the test results]]

Vital Signs

Procedures

[Include any procedures such as subcutaneous injections, sublingual immunotherapy starts or food or medication challenges, including the food or medication involved, the dosing, monitoring time, and symptoms due to the challenge, if relevant]]

Assessment and Plan

[The impression should include a numerical list of problems identified, each separated by a new paragraph; do not provide a detailed repeat of history. Take the assessment of the major problem to the highest level of diagnosis that you can, for example, “low back sprain caused by radiculitis involving left 5th LS nerve root.” Provide differential diagnoses for the major new problem if applicable. The plan is to include a specific diagnostic and specific treatment plan for each differential diagnosis. The diagnostic plan may include specific tests, procedures, other laboratory studies, consultations, etc. The treatment plan should include: patient education, pharmacotherapy if any, other therapeutic procedures. Document discussions of new medication or procedures including side effects, complications, & potential outcomes. Include patient education & any handouts provided] [If includes Allergic rhinitis Allergic rhinitis. [Skin prick testing today was unreliable, and I will further investigate with sIgE testing.] Avoidance measures were reviewed, and written information provided. Non-sedating antihistamines, nasal corticosteroids, and antihistamine eye drops can be used for symptom relief. Prescription for: [prescription names] was provided. [Pronoun] is a good candidate for immunotherapy if symptoms become medically refractory, or if allergy modifying therapy is desired. Based on the pattern of sensitization, [pronoun] is a candidate for [subcutaneous/sublingual] immunotherapy. [Pronoun] will contact my clinic directly for follow-up if [pronoun] become interested in immunotherapy. [Pronoun] is interested in pursuing sublingual immunotherapy. [Pronoun] is a candidate for [Acarizax (dust mite)/Itulatek (birch/tree)/Grastek (timothy/grass)]. A sublingual tablet is administered daily from home. A typical course of therapy is for 3 years, which has evidence of ongoing benefit after discontinuation for at least 2 years. The benefits and risks, including of oral pruritus, anaphylaxis and eosinophilic esophagitis were discussed. The first dose of each allergen must be administered in my clinic due to an elevated risk of anaphylaxis. [They will return in follow-up for initiation.] [Pronoun] is interested in pursuing subcutaneous immunotherapy. There is typically 6-9 months of weekly build-up injections, followed by monthly maintenance injections. Benefit is expected within 1-2 years. A typical course is 3-5 years, after which there should be lasting effect. Risks include life-threatening anaphylaxis were discussed. A prescription has been prepared. Once the serum is available, a follow-up visit will be arranged for first injection. [Pronoun] can then continue to receive injections with me, or with yourself if you agree.] [If Potential allergic rhinitis (if confirmation of diagnosis has not yet been done by skin testing or sIgE testing) [In person follow-up will be arranged for skin testing.] [Requisition was provided for sIgE testing to identify sensitization pattern.] Non-sedating oral antihistamines, intranasal corticosteroids, antihistamine eye drops can be used for empiric symptom relief. [A prescription for [medication names] was provided.] Immunotherapy may be an option. ] [If Non-allergic rhinitis. [Skin testing today did not clearly identify sensitization to an aeroallergen.] [Allergy testing patterns do not fully explain the patient’s symptoms.] [Requisition was provided to further investigate with sIgE testing.] Rarely, localized IgE production can occur. The differential diagnosis for non-allergic rhinitis is broad, including structural causes, irritant rhinitis, vasomotor rhinitis. Nasal steroids can continue to be used for symptom relief. [If no clear sensitization is found, referral to an otolaryngologist will be considered in follow-up. (if explicitly stated)] [Potential (if diagnosis not yet confirmed)] Asthma [, well/poorly controlled]. [Pre- and post-bronchodilator spirometry requisition was provided.] Recommended treatment: [Symbicort 200mcg PRN/Salbutamol PRN/Symbicort 200mcg 1 inh BID + PRN/Flovent 50/125/250mcg 1 inh BID/Alvesco 200mcg 1 inh daily/Atectura 80/160/320mcg 1 inh daily/Breo 100/200mcg 1 inh daily/Enerzair 160mcg 1 inh daily.] [Written asthma action plan was provided.] Poorly controlled asthma is a contraindication for immunotherapy. Routine vaccination, including with influenza, COVID-19 and RSV, is recommended if applicable. [[Pronoun] is a candidate for biologics given frequency of exacerbations. Requisition was provided for screening bloodwork to determine eligibility.] [If food allergy. Allergy to (list the foods). History, skin testing results [, and sIgE results] support a diagnosis of IgE-mediated allergy. [Requisition was provided for confirmation with sIgE testing.] [If sIgE results are borderline, in person follow-up for diagnostic confirmation with graded oral challenge will be considered.] [Many children with [egg/milk] allergy can still tolerate extensively baked forms. The Canadian [Egg/Milk] Ladder(s) was/were provided for guidance on gradual reintroduction of increasingly raw forms. I hope to reassess progress every 6 months.] [Outside of treatment,] Strict avoidance was recommended. Epinephrine autoinjector should be carried at all times. [EpiPen (Jr) was prescribed.] [Patient name] is a candidate for oral immunotherapy. Specific amounts of foods of concern will be given on a daily basis, with monthly updosing visits over the course of 1 year. A maintenance dose at around 300mg of food protein will then be consumed for 1-2 years. Sensitization will then be re-evaluated, and an oral challenge considered. The goal of therapy is increasing the reaction threshold. Long-term effects on prognosis is not well known. Risks including anaphylaxis and eosinophilic esophagitis were discussed. Outside of OIT, the foods should not be eaten. [[Pronoun] will return for initiation in follow-up.] [[Pronoun] will contact to initiate follow-up if [pronoun] become interested.]] [If introduction of common allergenic foods were discussed. Introduction of common allergenic foods. Early introduction and regular consumption of allergenic foods are the best ways to protect against food allergy. The list of common allergenic foods foods was reviewed. Written information was provided. [I will review progress in follow-up.]] [If oral allergy syndrome. Oral allergy syndrome. In this condition, proteins in fruits and vegetables mimic pollen proteins, and thus cause a localized allergic reaction. These proteins are heat and acid labile, and cooked forms of are typically tolerated. Patients also do not typically develop systemic symptoms such as anaphylaxis. Affected foods should be avoided in raw forms. Written information was provided.] [If atopic dermatitis/eczema. Atopic dermatitis. Principles of eczema management were reviewed and written information was provided. Regular moisturizing was recommended for prevention of flares. Topical medications should be aggressively used when flares develop, to minimize complications such as post-inflammatory hyperpigmentation and skin infections. [Prescription for: [medication names] was provided.] [We discussed that current understanding of eczema does not support food allergy as a driver. Avoidance of foods should be minimized as it can then lead to IgE-mediated food allergy.]] [If eosinophilic esophagitis. Eosinophilic esophagitis. [[Patient name] has a biopsy proven diagnosis of EoE.] Management approaches include dietary elimination and pharmacologic treatment. With dietary elimination, options including 2-food elimination diet, 4-food elimination diet, 6-food elimination diet and elemental diet are available, with varying success rates from 40-80%. Of note, skin test results-guided elimination diets do not have more success. Given the large number of foods involved, restrictive diets themselves can have impact on quality of life. [[Patient name] decided to proceed with the [name of the diet], which includes [foods involved], and expand further if necessary.][[Patient name] does not believe that dietary elimination would be practical for [pronoun] lifestyle.] Pharmacologic management options include PPIs, swallowed budesonide and escalation to dupilumab if needed. In light of ongoing symptoms, I have initiated therapy with [medication name and dose]. [I will reassess pharmacotherapy in [time].]] [If acute urticaria. Acute urticaria. In many individuals this is either spontaneous or viral induced. [Urticaria that lasts for over 24 hours are almost always not driven by allergy.] Some patients may also develop angioedema, which is a manifestation of the same interstitial edema in lower levels of the dermis. The condition is not life-threatening and usually improves after few days to few weeks. Laryngeal angioedema is not expected. [Patient name] was advised to keep at detailed food and medication diary if symptoms recur to ensure an allergic cause is not missed. Management is aimed at symptomatic control with nonsedating antihistamines.] [If chronic urticaria. Chronic spontaneous urticaria. Up to 40% of patients will also develop non-life-threatening angioedema that does not involve the larynx. [[Patient name] also has [symptomatic dermatographism/cholinergic urticaria/cold-induced urticaria] a form of chronic inducible urticaria triggered by [pressure on the skin (if symptomatic dermatographism)/increases in body temperature (if cholinergic urticaria)/contact with cold (if cold-induced urticaria).] Chronic nature of the condition was reviewed. In many individuals this condition is due to an autoimmune process in which autoantibodies our directed against the mast cells. This is a self-limiting condition but can take months to years to subside. [Blood work for associated conditions has been ordered.] Management is aimed at symptomatic control. The medications should continue to be used until the urticaria spontaneously resolves. First line treatment is with non-sedating antihistamines at up to 4x labelled dose. If not responding to high-dose antihistamines than omalizumab or cyclosporin would be options. Short course of oral corticosteroids can be used for severe exacerbations. [A prescription for [medication name] was provided.] Advised to avoid NSAIDs and alcohol which can exacerbate the condition.] [If penicillin allergy. Penicillin allergy. Penicillin allergy is commonly reported (around 10% of the population), but most patients with a penicillin allergy label can tolerate penicillin. This is most commonly secondary to misattributed symptoms due to other comorbidities. Sensitization can also be lost over time (80% in 10 years). A penicillin allergy label is associated with multi-drug resistant organisms, and prolonged hospital stays. [Given remote reaction with low risk features, direct oral amoxicillin challenge is recommended. Amoxicillin will be administered, and [pronoun] will be monitored for 1 hour for features of immediate hypersensitivity.] [Given elevated risk from history, we will first proceed with intradermal skin testing to penicillin and its derivatives. If skin testing is negative, oral challenge to amoxicillin will be considered.] The risks and benefits were discussed, and [Patient name] is agreeable with proceeding when [pronoun] returns in follow-up. If [pronoun] is asymptomatic, [pronoun] has the same risk of penicillin allergy as the general population, and the allergy label can be removed.] For all other problems mentioned, write as instructed in the beginning. [Diagnosis or diagnostic impression of the patient's condition (only include if explicitly mentioned), any discussion and explanation given to parents about the disease or condition or symptoms consistent with the diagnostic impression, summary of key findings (only include if applicable)], [Differential diagnoses (only include if applicable)], [Recommendations for treatment, management, medications, referrals or involvement of other professionals, investigations. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]

Assessment and Plan

[The impression should include a numerical list of problems identified, each separated by a new paragraph; do not provide a detailed repeat of history. Take the assessment of the major problem to the highest level of diagnosis that you can, for example, “low back sprain caused by radiculitis involving left 5th LS nerve root.” Provide differential diagnoses for the major new problem if applicable. The plan is to include a specific diagnostic and specific treatment plan for each differential diagnosis. The diagnostic plan may include specific tests, procedures, other laboratory studies, consultations, etc. The treatment plan should include: patient education, pharmacotherapy if any, other therapeutic procedures. Document discussions of new medication or procedures including side effects, complications, & potential outcomes. Include patient education & any handouts provided] [If includes Allergic rhinitis Allergic rhinitis. [Skin prick testing today was unreliable, and I will further investigate with sIgE testing.] Avoidance measures were reviewed, and written information provided. Non-sedating antihistamines, nasal corticosteroids, and antihistamine eye drops can be used for symptom relief. Prescription for: [prescription names] was provided. [Pronoun] is a good candidate for immunotherapy if symptoms become medically refractory, or if allergy modifying therapy is desired. Based on the pattern of sensitization, [pronoun] is a candidate for [subcutaneous/sublingual] immunotherapy. [Pronoun] will contact my clinic directly for follow-up if [pronoun] become interested in immunotherapy. [Pronoun] is interested in pursuing sublingual immunotherapy. [Pronoun] is a candidate for [Acarizax (dust mite)/Itulatek (birch/tree)/Grastek (timothy/grass)]. A sublingual tablet is administered daily from home. A typical course of therapy is for 3 years, which has evidence of ongoing benefit after discontinuation for at least 2 years. The benefits and risks, including of oral pruritus, anaphylaxis and eosinophilic esophagitis were discussed. The first dose of each allergen must be administered in my clinic due to an elevated risk of anaphylaxis. [They will return in follow-up for initiation.] [Pronoun] is interested in pursuing subcutaneous immunotherapy. There is typically 6-9 months of weekly build-up injections, followed by monthly maintenance injections. Benefit is expected within 1-2 years. A typical course is 3-5 years, after which there should be lasting effect. Risks include life-threatening anaphylaxis were discussed. A prescription has been prepared. Once the serum is available, a follow-up visit will be arranged for first injection. [Pronoun] can then continue to receive injections with me, or with yourself if you agree.] [If Potential allergic rhinitis (if confirmation of diagnosis has not yet been done by skin testing or sIgE testing) [In person follow-up will be arranged for skin testing.] [Requisition was provided for sIgE testing to identify sensitization pattern.] Non-sedating oral antihistamines, intranasal corticosteroids, antihistamine eye drops can be used for empiric symptom relief. [A prescription for [medication names] was provided.] Immunotherapy may be an option. ] [If Non-allergic rhinitis. [Skin testing today did not clearly identify sensitization to an aeroallergen.] [Allergy testing patterns do not fully explain the patient’s symptoms.] [Requisition was provided to further investigate with sIgE testing.] Rarely, localized IgE production can occur. The differential diagnosis for non-allergic rhinitis is broad, including structural causes, irritant rhinitis, vasomotor rhinitis. Nasal steroids can continue to be used for symptom relief. [If no clear sensitization is found, referral to an otolaryngologist will be considered in follow-up. (if explicitly stated)] [Potential (if diagnosis not yet confirmed)] Asthma [, well/poorly controlled]. [Pre- and post-bronchodilator spirometry requisition was provided.] Recommended treatment: [Symbicort 200mcg PRN/Salbutamol PRN/Symbicort 200mcg 1 inh BID + PRN/Flovent 50/125/250mcg 1 inh BID/Alvesco 200mcg 1 inh daily/Atectura 80/160/320mcg 1 inh daily/Breo 100/200mcg 1 inh daily/Enerzair 160mcg 1 inh daily.] [Written asthma action plan was provided.] Poorly controlled asthma is a contraindication for immunotherapy. Routine vaccination, including with influenza, COVID-19 and RSV, is recommended if applicable. [[Pronoun] is a candidate for biologics given frequency of exacerbations. Requisition was provided for screening bloodwork to determine eligibility.] [If food allergy. Allergy to (list the foods). History, skin testing results [, and sIgE results] support a diagnosis of IgE-mediated allergy. [Requisition was provided for confirmation with sIgE testing.] [If sIgE results are borderline, in person follow-up for diagnostic confirmation with graded oral challenge will be considered.] [Many children with [egg/milk] allergy can still tolerate extensively baked forms. The Canadian [Egg/Milk] Ladder(s) was/were provided for guidance on gradual reintroduction of increasingly raw forms. I hope to reassess progress every 6 months.] [Outside of treatment,] Strict avoidance was recommended. Epinephrine autoinjector should be carried at all times. [EpiPen (Jr) was prescribed.] [Patient name] is a candidate for oral immunotherapy. Specific amounts of foods of concern will be given on a daily basis, with monthly updosing visits over the course of 1 year. A maintenance dose at around 300mg of food protein will then be consumed for 1-2 years. Sensitization will then be re-evaluated, and an oral challenge considered. The goal of therapy is increasing the reaction threshold. Long-term effects on prognosis is not well known. Risks including anaphylaxis and eosinophilic esophagitis were discussed. Outside of OIT, the foods should not be eaten. [[Pronoun] will return for initiation in follow-up.] [[Pronoun] will contact to initiate follow-up if [pronoun] become interested.]] [If introduction of common allergenic foods were discussed. Introduction of common allergenic foods. Early introduction and regular consumption of allergenic foods are the best ways to protect against food allergy. The list of common allergenic foods foods was reviewed. Written information was provided. [I will review progress in follow-up.]] [If oral allergy syndrome. Oral allergy syndrome. In this condition, proteins in fruits and vegetables mimic pollen proteins, and thus cause a localized allergic reaction. These proteins are heat and acid labile, and cooked forms of are typically tolerated. Patients also do not typically develop systemic symptoms such as anaphylaxis. Affected foods should be avoided in raw forms. Written information was provided.] [If atopic dermatitis/eczema. Atopic dermatitis. Principles of eczema management were reviewed and written information was provided. Regular moisturizing was recommended for prevention of flares. Topical medications should be aggressively used when flares develop, to minimize complications such as post-inflammatory hyperpigmentation and skin infections. [Prescription for: [medication names] was provided.] [We discussed that current understanding of eczema does not support food allergy as a driver. Avoidance of foods should be minimized as it can then lead to IgE-mediated food allergy.]] [If eosinophilic esophagitis. Eosinophilic esophagitis. [[Patient name] has a biopsy proven diagnosis of EoE.] Management approaches include dietary elimination and pharmacologic treatment. With dietary elimination, options including 2-food elimination diet, 4-food elimination diet, 6-food elimination diet and elemental diet are available, with varying success rates from 40-80%. Of note, skin test results-guided elimination diets do not have more success. Given the large number of foods involved, restrictive diets themselves can have impact on quality of life. [[Patient name] decided to proceed with the [name of the diet], which includes [foods involved], and expand further if necessary.][[Patient name] does not believe that dietary elimination would be practical for [pronoun] lifestyle.] Pharmacologic management options include PPIs, swallowed budesonide and escalation to dupilumab if needed. In light of ongoing symptoms, I have initiated therapy with [medication name and dose]. [I will reassess pharmacotherapy in [time].]] [If acute urticaria. Acute urticaria. In many individuals this is either spontaneous or viral induced. [Urticaria that lasts for over 24 hours are almost always not driven by allergy.] Some patients may also develop angioedema, which is a manifestation of the same interstitial edema in lower levels of the dermis. The condition is not life-threatening and usually improves after few days to few weeks. Laryngeal angioedema is not expected. [Patient name] was advised to keep at detailed food and medication diary if symptoms recur to ensure an allergic cause is not missed. Management is aimed at symptomatic control with nonsedating antihistamines.] [If chronic urticaria. Chronic spontaneous urticaria. Up to 40% of patients will also develop non-life-threatening angioedema that does not involve the larynx. [[Patient name] also has [symptomatic dermatographism/cholinergic urticaria/cold-induced urticaria] a form of chronic inducible urticaria triggered by [pressure on the skin (if symptomatic dermatographism)/increases in body temperature (if cholinergic urticaria)/contact with cold (if cold-induced urticaria).] Chronic nature of the condition was reviewed. In many individuals this condition is due to an autoimmune process in which autoantibodies our directed against the mast cells. This is a self-limiting condition but can take months to years to subside. [Blood work for associated conditions has been ordered.] Management is aimed at symptomatic control. The medications should continue to be used until the urticaria spontaneously resolves. First line treatment is with non-sedating antihistamines at up to 4x labelled dose. If not responding to high-dose antihistamines than omalizumab or cyclosporin would be options. Short course of oral corticosteroids can be used for severe exacerbations. [A prescription for [medication name] was provided.] Advised to avoid NSAIDs and alcohol which can exacerbate the condition.] [If penicillin allergy. Penicillin allergy. Penicillin allergy is commonly reported (around 10% of the population), but most patients with a penicillin allergy label can tolerate penicillin. This is most commonly secondary to misattributed symptoms due to other comorbidities. Sensitization can also be lost over time (80% in 10 years). A penicillin allergy label is associated with multi-drug resistant organisms, and prolonged hospital stays. [Given remote reaction with low risk features, direct oral amoxicillin challenge is recommended. Amoxicillin will be administered, and [pronoun] will be monitored for 1 hour for features of immediate hypersensitivity.] [Given elevated risk from history, we will first proceed with intradermal skin testing to penicillin and its derivatives. If skin testing is negative, oral challenge to amoxicillin will be considered.] The risks and benefits were discussed, and [Patient name] is agreeable with proceeding when [pronoun] returns in follow-up. If [pronoun] is asymptomatic, [pronoun] has the same risk of penicillin allergy as the general population, and the allergy label can be removed.] For all other problems mentioned, write as instructed in the beginning. [Diagnosis or diagnostic impression of the patient's condition (only include if explicitly mentioned), any discussion and explanation given to parents about the disease or condition or symptoms consistent with the diagnostic impression, summary of key findings (only include if applicable)], [Differential diagnoses (only include if applicable)], [Recommendations for treatment, management, medications, referrals or involvement of other professionals, investigations. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]

Follow-up

["I will see the patient again in" [specify patient's name, and when I said I would see them again and specify in person, virtually or via phone.] [Specify under what conditions to return earlier (only include if applicable)] ] [[patient's name] will call to initiate follow-up once investigations are complete.] [No definitive follow-up plans, but I am happy to reassess as the need arises. (if no follow-up plans)]

Closure

Thank you for the opportunity to be a part of her care. Please do not hesitate to contact with any questions or concerns.