Clinical Connectathon Allergy and Intolerance Use Case – Clinician and Patient
generated data.
(Elaine and Russ)
Creation and Maintenance of List of Allergic or Intolerance Conditions including
Patient Generated Data
Description
The purpose of this use case is to describe a series of events related to the creation and
maintenance of an allergic and intolerance list of conditions including patient generated
data from a personal health record.
Exclusions
The evaluation of the allergic or intolerance condition by an allergy specialist and
confirmation of reactions by testing or direct challenge.
Preconditions
None
Use Case Sequence of Steps
1.
A patient visited an urgent care center complaining of a sore throat. The throat
culture showed Group A strep, sensitive to penicillin.
2.
The patient started on penicillin V 500 mg qid with a 10 day course
3.
On the 8th day of treatment the patient experienced hives, nausea, abdominal
pain, and diarrhea 30 minutes after taking his morning dose of penicillin.
4.
The patient scheduled a visit that afternoon with his primary care provider
(PCP) .
5.
Symptoms reported to his PCP include rash, diarrhea and abdominal pain.
6.
The patient reports an existing allergy to walnuts (hives) and lactose intolerance
(abdominal pain and diarrhea).
7.
The primary care provider takes a history and performance a physical
examination.
8.
Findings documented include......
a. Adverse reaction to penicillin, severity – moderate.
9.
The PCP creates a new allergy and intolerance list including:
a. Allergy to penicillin
i. Observed adverse reaction (rash)
ii. Criticality – Critical (High)
b. Allergy to walnuts
i. Patient reported
ii. Criticality – Not known
c. Intolerance to Lactose
i. Patient reported
ii. Criticality – Not known
10.
11.
12.
13.
14.
15.
16.
17.
The patient receives a prescription for erythromycin as an alternative treatment
for his strep throat.
The patient returns home and logs into his personal health record
The patient now reviews his allergy and intolerance list noting penicillin allergy,
allergy to walnuts and lactose intolerance.
The patient realizes that he forgot to tell his PCP about a reaction he had to a flu
vaccine last year. He adds “allergy to flu vaccine” to his allergy and intolerance
list.
The patient returns to his PCP for a follow up visit after finishing his course of
erythromycin.
The PCP confirms that the strep throat is resolved and asks the patient about his
allergy to flu vaccine. The patient reports that he felt sick after receiving the
shot – fever, aches and some swelling at the injection site. PCP verifies that
patient has no known allergy to eggs.
The PCP notes in the chart:
a. Adverse reaction to flu shot – severity – mild.
The PCP reviews and updates the allergy and intolerance list:
a. Adverse reaction to flu shot – severity – mild
i. This entry updates patient entry of “allergy to flu vaccine”
b. No known allergy to eggs
c. Patient reported
Post Condition
Reconciled list of allergy and intolerances is part of patient record(s). Changes updated in
patient’s PHR.