Age: 4.0
Sex: M
Vaccine: DTAP, HEP, HEPA, IPV, MMR, VARCEL
Symptoms: Injection site pruritus, Learning disability, No reaction on previous exposure to drug, Pain, Rash macular
Clinical narrative: Vitals Written @ 28 Mar 2008 1346 PDT BP: 90/54, HR: 95, RR: 18, T: 98.1 °F, WT: 40.75 lbs,  Pain Scale: 4/5 Hurts Whole Lot, Pain Scale Comments: head  Comments: Pt shows age related barriers to learning.     SO Note Written  @ 28 Mar 2008 1507 PDT Chief complaint  The Chief Complaint is: Rash following immunizations on 3/26/08. History of present illness   The Patient is a 4 year old male.   He reported: Skin lesion(s):  4 yo male received immunizations 26-Mar-08 - IPV, MMR, Varicella, DTAP, Heb B, and Hep A.  Patient has received all of these immunizations except Hep A in the past without adverse reaction.  Mother reports she noted a large area of redness on the child's R. anterior thigh at the injection site, a rash on the child's abdomen, and redness and swelling in the child's face the following morning.  No fever. No cough, SOB, or wheezing.  Rash resolving with hydrocortisone.  Child c/o itching at injection site.  No reaction at site on L. thigh where immunizations given.  Child with previous history of rash with PCN and Amoxicillin. Past medical/surgical history  Reported History: No past medical history reported current medications: Hyrocortisone. Surgical / procedural: No surgical / procedural history. Personal history  Behavioral history: No tobacco use No second hand smoke exposure. Family history   No hypertension   No hyperlipidemia   No diabetes mellitus. Review of systems  Systemic symptoms: Not feeling tired or poorly.  No fever and no recent weight change. Physical findings  Vital signs: ° Current vital signs reviewed. General appearance: ° Well-appearing.  ° Awake.  ° Alert.  ° Well developed.  ° Well nourished.  ° In no acute distress. Oral cavity: ° Normal. Pharynx: Oropharynx: ° Posterior pharyngeal wall was normal. Lymph Nodes: ° Cervical lymph nodes were not enlarged.  ° Submandibular lymph nodes were not enlarged.  ° Consistency was normal.  ° Mobile. Lungs: ° Respiratory movements were normal.  ° Clear to auscultation.  ° No wheezing was heard.  ° No rhonchi were heard.  ° No rales/crackles were heard. Cardiovascular system: Heart Rate And Rhythm: ° Normal. Heart Sounds: ° S1 normal.  ° S2 normal. Neurological: Gait And Stance: ° Normal. Skin: o Skin: approximately 3 X 3 inch area of raised erythema on R. anterior thigh at site of injections.  No iduration or warmth.  No tenderness to palpation.  Faint erythematous/macular rash on abdomen.  Faint erythema above R. eyebrow.  No swelling in face. Hair: ° Normal. Nails: ° Normal.      A/P Written @ 28 Mar 2008 1511 PDT  1. ALLERGIC REACTION: possible allergic reaction to immunizations.  ? Hep A.  Site specific immunizations not recorded in medical record.  Referral placed to allergy clinic for further evaluation.  Consult(s):   -Referred To: ALLERGY/IMMUNOLOGY (Routine) Specialty:  Clinic: ALLERGY CLINIC Primary Diagnosis: ALLERGIC REACTION   Disposition Written  @ 28 Mar 2008 1511 PDT  Released w/o Limitations  Follow up:  as needed .  Discussed: Diagnosis, Medication(s)/Treatment(s), Alternatives, Potential Side Effects with Patient who indicated understanding.  Administrative Options: Consultation requested    Signed By (ARNP (Family Nurse Practitioner), MAMC) @ 28 Mar 2008 1521    Note Written @ 28 Mar 2008 1520 PDT (Added after encounter was signed.)  Discussed symptomatic treatment for localized skin reaction.  May continue hydrocortisone PRN.  OTC Benadryl PRN  _________________________________________________________________________________________________________  CHANGE HISTORY The following Signature(s) No Longer Applies because this Encounter Was Opened for Amendment @ 28 Mar 2008 1520 PDT: Signed  (ARNP (Family Nurse Practitioner), MAMC) @ 28 Mar 2008 1511  The following Vitals Entry Was Overwritten @ 28 Mar 2008 1351 PDT: Vitals Written @ 28 Mar 2008 1346 PDT  BP: 90/54, HR: 95, T: 98.1 °F, WT: 40.75 lbs,  Pain Scale: 4/5 Hurts Whole Lot, Pain Scale Comments: head  Comments: Pt shows age related barriers to learning.