Chapter 5: The Lymphatic and Immune Systems | Carter Rosari's Chart Note

CHART NOTE

Patient Name: Rosari, Carter
ID Number: CR8062
Examination Date: November 21, 20xx

SUBJECTIVE
Carter presents with multiple raised, red, itchy welts on his lower leg, thigh, and forearm after returning home from a camping trip with his Boy Scout troop. He states that it started about 3 days into the trip and that some of the welts seemed to get better, but then new ones began to erupt. "They seemed to move up my leg and onto my arm." He remembers something similar to this happening last year when he helped his father put up the Christmas tree.

OBJECTIVE
Wheals (welts or swellings) ranging in size from small spots on the left forearm to several large blotches about 1—2 cm in diameter on the lower leg and thigh. No fever. Vital signs are normal. History of pollen allergy.

ASSESSMENT
Urticaria (hives) of left leg and forearm. Allergic contact dermatitis.

PLAN
Apply hydrocortisone cream to the affected areas. Patient to return if condition does not improve or worsens.