Posted: July 14th, 2022

History of present illness (HPI)

Subjective Findings
Subjective findings:
Chief complaint (cc), history of present illness (HPI) must include PQRST or OLDCARTS
Allergies, prescription/OTC/herbal medications, Past medical/surgical/social/family history/psychiatric history/developmental and pregnancy history, hospitalizations
Problem-focused review of systems (ROS)
1 pts
Proficient
Documents all subjective information listed
0.5 pts
Competent
Documents most subjective information listed
0 pts
Novice
Documents most subjective information listed Leaves out large amount of information or documents objective findings
1 pts
This criterion is linked to a Learning OutcomeObjective Findings
Complete Mental Status Examination including results of diagnostic testing conducted at the time of the visit OR previously done and being used to support the diagnosis and management plan for the current visit.
1.5 pts
Proficient
Documents all objective information listed
0.75 pts
Competent
Documents most objective information listed
0 pts
Novice
Leaves out large amount of information or documents subjective information
1.5 pts
This criterion is linked to a Learning OutcomeAssessment
Present three (3) differential and one (1) final diagnosis. Use correct ICD-10 codes for each. Final diagnoses will include any active medical problems being addressed in patient education and treatment plan.
1 pts
Proficient
Provides 3 ddx and 1 final dx (with ICD-10 codes)
0.5 pts
Competent
Provides < 3 ddx or fails to provide ICD-10 codes
0 pts
Novice
Provides < 3 ddx and/or fails to provide ICD-10 codes and fails to identify final dx
1 pts
This criterion is linked to a Learning OutcomePlan
Identify diagnostics, prescriptions, referrals, patient education, and recommended follow-up. Use CPT billing codes for office visit (level of service) and for testing conducted during the office visit.

Prescriptions: Correctly write out a prescription for one medication prescribed for the patient. If you did not prescribe medication, write out a prescription for a medication that might be prescribed for a similar patient
1 pts
Proficient
Documents full and appropriate plan of care .
0.5 pts
Competent
Documents partial plan of care, missing few pieces
0 pts
Novice
Documents limited or inappropriate plan of care, missing many pieces
1 pts
This criterion is linked to a Learning OutcomeSources
Cite at least 1 current evidence-based guideline to support your patient education and treatment plan in APA format.
0.5 pts
Proficient
Cites one (1) evidence-based guideline in APA format
0 pts
Novice
Does not cite one (1) evidence-based guideline

SOAP NOTE
Date:
Name:
Institution:

SOAP NOTE
Subjective Findings
Chief complaint (cc), history of present illness (HPI) must include PQRST or OLDCARTS Allergies, prescription/OTC/herbal medications, Past medical/surgical/social/family history/psychiatric history/developmental and pregnancy history, hospitalizations
The client’s history of present illness(HPI) includes allergies. According to the PQRST, or OLD CARTS, the symptom. The patient’s constitutional symptoms include rashes, swollen lips, itchy and watering eyes, sneezing, blocked nose, skin rashes, and scratchy throat. The allergic reaction is mainly caused by the intake of certain foods, certain medications, and exposure to pollen. According to PQRST or OLD CARTS assessment, the patient’s allergic condition is chronic and gradual, aggravated by environmental factors, such as exposure to pollen grains, types of medications, and many other allergens (Cox, Sanchez-Borges, and Lockey, 2017).
Identifying Information
The patient is male gender and African black American, forty years of age.
Chief Complaint (CC)
The reason for seeking medical attention is an allergic condition, which has been persistent and gradual for the past year. The main symptoms include tummy pain, swollen lips, itchy and watering eyes, sneezing, blocked nose, skin rashes, and scratchy throat.
History of Present Illness (HPI)
Provocative: The allergy is accelerated by certain types of foods taken
Quality: the allergy is severe, affecting various organs, such as the eyes and throats.
Radiation; The allergy radiates more around the face, affecting the eyes and nose, causing scratchy throat and pain in the stomach.
Severity: the allergy is wrong and requires urgent treatment to reduce uncomfortably.
Timing: The allergy started ten months ago, but it has grown gradually to uncomfortable symptoms.
Past Medical History (PMH)
The patient has a medical history of persistent flu, and the family has a medical history of asthma and anaphylaxis. The patient, however, has a history of surgeries.
Drug History (DH)
The current drug used is an over-the-counter drug called antihistamine that Helps in relieving allergies (Cox, Sanchez-Borges, and Lockey, 2017). The medicine has been used for the past four months due to persistent allergic reactions. The patient has no history of narcotic drugs, such as caffeine or any illicit drugs.
Family History (FH)
The family has a medical history of asthma, where most close family members are diagnosed with asthma.
Social History (SH)
The patient is a sales and delivery person in a sound re-known company in the city. The patient has no health insurance cover from the company, hence independent.
Review of Systems (ROS)
Use of PQRST or OLD CARTS assessment tolls for positive symptoms
Common symptoms in major body systems
Common symptoms in each significant body system.
A general head-to-toe format.
Documentation of all subjective information
Complete Mental Status Examination
The mental health status focuses on the patient’s mood, speech, behavior judgment, perceptual disturbances, and cognition. During the interview, the patient appeared agitated when asked questions, restless, and kept shifting seats (Cox, Sanchez-Borges, and Lockey, 2017). The patient’s speech was over-elaborate and loud; The patient denied having suicidal thoughts or poor relationships with colleagues at work. Additionally, the patient had poor judgment.
Present three (3) differential and one (1) final diagnosis.
Through an allergy skin and blood test under testing standards, the doctor discovered allergens on the skin. The skin test was conducted by injecting a small amount of allergen into the skin, which showed venom and drug allergies (Cox, Sanchez-Borges, and Lockey, 2017). The intradermal skill-testing was used to assess any internal food allergies. Blood allergies determined the number of antibodies the body uses to fight the allergies.
Identify diagnostics, prescriptions, referrals, patient education, and recommended follow-up.
The patient was diagnosed with anaphylaxis, an allergic condition that occurs when a person is exposed to allergens. The anaphylaxis condition primarily affects the skin, and respiratory system, leading to wheezing, low blood pressure, itchiness, changes in heart rate, and difficulties breathing. The leading cause of the issue is less production of antibodies that fight foreign substances in the body (Cox, Sanchez-Borges, and Lockey, 2017). There is no specific way to cure anaphylaxis, but methods to manage the conditions are present; the patient can take necessary measures to avoid exposure to allergens. Additionally, the patient can use an identification bracelet, which provides details concerning an allergy. Another treatment method is the use of an auto-injector and frequent allergy testing.
The patient should receive health education concerning allergens, precautions to take, as well as use of medicine. Apart from getting education, and use of medication, the patient is expected to visit the hospital for clinics thrice a month to examine any medication side effect, and the situation of the disease. I would recommend the patient to avoid crowded places, change of work duties, and maintain high hygienic standards, especially living in a dist-free area.
Prescriptions
The patient can use H1 antihistamines and epinephrine, which are certified by the world allergy association update. If the patient does not prefer oral intake, an intramuscular injection can be provided at the anterolateral thigh. Epinephrine is the most effective medication for severe reactions, hence a first-line treatment.

References
Cox, L. S., Sanchez-Borges, M., & Lockey, R. F. (2017). World Allergy Organization systemic allergic reaction grading system: is a modification needed?. The Journal of Allergy and Clinical Immunology: In Practice, 5(1), 58-62.

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