Age: 38.0
Sex: F
Vaccine: TDAP
Symptoms: Pharyngolaryngeal pain, Pruritus, Rash papular, Skin warm, Urine output increased
Clinical narrative: (see attached); 9/4/2008 Thursday, 18:00 small pimple like eruptions on both forearms and left hand (linear arrangement, 2 to 3 in a row), 20:00 diphenhydramine elixer 25 mg orally prior to bed; 9/5/2008 Friday, 7:00 more small eruptions on right upper chest, both upper arms, facial flushing of both cheeks, mild itching, 7:30 loratidine 10 mg orally prior to going to work, 12:30 eruptions on left shoulder, mild joint arthralgia (elbows, hips, knees, ankles), mild headache, 12:30 acetaminophen 500 mg orally, diphenhydramine cream topically to arm and chest rash, 17:30 diphenhydramine elixer 50 mg orally when arrive home; hydrocortisone cream topical, 20:00 loratidine 10 mg orally prior to bed, Increased itchiness along arms and upper chest during night; 9/6/2008 Saturday, 8:30 small eruptions have become nickel and quarter sized raised welts on outer surface of arms, shoulders, upper chest, left neck, both eyelids, right buttock. Upper arms tight, itchy, and hot to touch. Sore throat with cough noticeable. 9:30 call insurance 1-800 number to get authorization to go Urgent Care or Emergency Room, instructed to leave message, 10:15 no call back from insurance line, 10:30 registered at Medical Center Emergency Department, at triage, temperature and blood pressure normal, 11:00 while waiting to be seen by MD/PA, continued hive eruptions on both hands (knuckles and along left side of fingers), leg and inner left ankle area, 11:30 diagnosis: allergic reaction post ADACEL vaccination, 11:45 methylprednisone 125 mg intramuscularly x 1, ranitidine 300 mg orally x 1, hydroxyzine 50 mg orally x 1 Emergency Dept.. Instructed by PA to continue loratidine 10 mg daily and diphenhydramine 50-100 at bedtime. Rapid strep culture negative. 12:40 prescriptions prednisone (60 mg daily x 3 days, 40 mg daily x 2 days, 20 mg daily x 3 days, 10 mg daily x 7 days), ranitidine 300 mg twice, hydroxyzine 25-500 mg every 6 hrs PRN for itching, 13:00 1st dose of prednisone 60 mg taken with lunch along with loratidine 10 mg. Cold towel compresses to arms and chest per PA recommendation. Took 1.5 hour nap. 14:30 welts appear less red and hot. White ring forming around outer perimeter of welts. Some welts have flattened but appear red pinprick (hemolytic?) Neck and facial eruptions decreased. Sore throat no longer notable. New eruptions (small eruptions) in pairs on lower back above spine and on sides above both hips, 17:00 hydroxyzine 50 mg orally for itching, 20:00 ranitidine 300 mg and loratidine 10 mg. Cold shower per PA recommendation; 9/7/2008 Sunday, 2:00 hydroxyzine 50 mg (awoke due to itching), 7:30 welt margins flattened and fading but centers still raised. Neck welts diminished. New single eruptions on sides of left knee and right upper forehead. Continued itchiness when drugs wear off. 8:00 ranitidine 300 mg and loratidine 10 mg, 9:45 prednisone 60 mg and hydroxyzine 25 mg orally after breakfast, 13:30 hydroxyzine 25 mg for continued arm itching, 16:30 bowel movement - soft stools; 20:00 ranitidine 300 mg and loratidine 10 mg, 21:30 cold shower, diphenhydramine elixer 50 mg before bed; 9/8/2008 Monday, 4:00 hydroxyzine 50 mg for upper arm itching, 6:30 welts distant from injection site (hands, forearms, neck, face, upper right chest, feet/ankle) diminished to small pimple-like eruptions. Upper arm welts diminished in diameter. Pink/reddish color faded. Facial eruptions stable/still visible. 7:00 prednisone 60 mg, loratidine 10 mg, ranitidine 300 mg before going to work. 10:30 diphenhydramine capsule 50 mg taken for increased itchiness of arms and chest, difficulty seeing well throughout day, 17:00 hydroxyzine 50 mg at home for itchiness, 19:15 ranitidine 300 mg and loratidine 10 mg with dinner, 20:00 luke warm shower/cold rinse. Experienced left foot cramping (noted increase urine volumes during voiding throughout day). Diphenhydramine capsule 50 mg at bedtime, eruptions stable, no new eruptions noted; 9/9/2008 Tuesday, 2:30 Awoke from sleep. Very mild itching. 6:15 Eruptions stable and margins fading. Mild itchiness around upper arm and neck eruptions. 6:45 prednisone 40 mg, loratidine 10 mg, ranitidine 300 mg with breakfast, 10:30 hydroxyzine 25 mg for mild upper arm itching, 20:30 note new single hive on outer left foot below ankle, on right cheek, and under chin, 21:00 ranitidine 300 mg and diphenhydramine capsule 50 mg after cool bath, 22:30 diphenhydramine elixer 25 mg for continued mild itching; 9/10/2008 Wednesday, 6:30 Upper arm and chest hives stable, red/pink margins fading on forearms, redness diminished, facial hives no change, 7:15 prednisone 40 mg and ranitidine 300 mg before work, 8:00 diphenhydramine capsule 50 mg, 12:00 note 3 small eruptions along edge of outer palm on left hand, 20:00 ranitidine 300 mg and diphenhydramine 50 mg; 9/11/2008 Thursday, 8:00 2 eruptions on right middle back, 1 eruption on middle finger of right hand, existing eruptions stable, 8:00 prednisone 40 mg, ranitidine 300 mg, diphenhydramine elixer 25 mg, 14:30 diphenhydramine 25 mg capsule, 21:30 ranitidine 300 mg and diphenhydramine 50 mg capsule; 9/12/2008 Friday, 7:30 existing eruptions stable - no change, new smaller eruptions on right hand between thumb and index finger, 8:00 prednisone 20 mg, ranitidine 300 mg, diphenhydramine 25 mg capsule