ED Visit 5/2: 31 y.o. female, seen on 05/02/2021 at 23:16 for red, pruritic rash, onset this morning. Patient reports that she was in her usual state of health until this morning when she awoke with an itchy rash over her buttocks that spread to her bilateral legs, arms, and now left eye. Patient states that she last took a Benadryl at 18:00 this evening and applied topical cream without relief of itching. She adds that she had dinner in a garden last night, but she states that she did not consume tree nuts which is her known allergy. Patient denies fever, chills, cough, shortness of breath, sore throat, throat swelling, or chest pain. She also denies nausea, vomiting, changes in bowel habits, or abdominal pain.  Vitals: 05/02/21 2319  37.3 °C (99.1 °F) 105 18 126/83 100 %   Pt given: EPINEPHrine (PF) (ADRENALIN) injection 0.15 mg 0.15 mg Subcutaneous methylPREDNISolone sod suc(PF) (SOLU-Medrol) injection 125 mg 125 mg IntraVenous diphenhydrAMINE (BENADRYL) injection 50 mg 50 mg IntraVenous  pt discharged w/ diphenhydramine and prednisone taper  5/4 Urgent Care: TM clear, nose clear, throat- no tongue swelling, uvula midline.  Chest- clear s1s2 regular Abdomen soft non tender. Extremity - mild warmth, swelling and tenderness 2-3 MCP joint area. Range of motion limited due to swelling and pain Knee rashes anteriorly but range of motion normal. Skin - localized urticarial rash over bilateral lower/upper extremity. Erythematous rash over face, with mild swelling. Swelling also over sides of nasal bridge. Acne bilateral cheek area but more erythematous. No lip swelling. tongue coated but no swelling. No soft palate swelling.uvula midline Neuro grossly intact strength 5/5 upper/lower extremity, sensation normal   Course in Clinic- Epinephrine 0.3 mg subcutaneous - minimal improvement Case discussed with on call allergist -Dr- recommended Kenalog 60 mg IM - patient observed in clinic for 3 hrs - felt better. Rash swelling face better, sob better, hand pain swelling persisted  Patient also given 1 l normal saline- as she says she has not been drinking much and elevated creatinine.  Labs -  Component Latest Ref Rng & Units 5/4/2021  WBC 4.0 - 11.0 K/uL 24.2 (H)  RBC 3.90 - 5.40 M/uL 4.33  Hemoglobin 12.0 - 15.5 g/dL 13.8  Hematocrit 35.0 - 47.0 % 40.1  MCV 80 - 100 fL 93  MCH 27.0 - 33.0 pg 31.9  MCHC 31.0 - 36.0 g/dL 34.4  RDW <16.4 % 12.1  Platelet Count 150 - 400 K/uL 229  Differential Type Automated  Neutrophil % % 70  Lymphocyte % % 26  Monocyte % % 4  Eosinophil % % 0  Basophil % % 0  Abs Neutrophil 2.0 - 8.0 K/uL 16.7 (H)  Abs Lymphocyte 1.0 - 5.1 K/uL 6.3 (H)  Abs Monocyte 0.0 - 0.8 K/uL 0.8  Abs Eosinophil 0.0 - 0.5 K/uL 0.0  Abs Basophil 0.0 - 0.2 K/uL 0.0  Sodium 136 - 145 mmol/L 141  Potassium 3.5 - 5.1 mmol/L 3.4 (L)  Chloride 98 - 110 mmol/L 107  CO2 (Bicarbonate) 21 - 32 mmol/L 23  Glucose 70 - 99 mg/dL 143 (H)  Urea Nitrogen (BUN) 6 - 25 mg/dL 10  Creatinine 0.40 - 1.00 mg/dL 1.06 (H)  GFR Est-Other >60 See Cmnt 70  GFR Est-African American >60 See Cmnt 81  Calcium 8.2 - 10.2 mg/dL 8.8  Total Protein 6.4 - 8.2 g/dL 8.0  Albumin 3.2 - 4.7 g/dL 3.8  Bilirubin Total <1.1 mg/dL 0.5  Alkaline Phosphatase 26 - 137 U/L 87  AST 0 - 37 U/L 19  ALT 0 - 60 U/L 17   Patient observed for more than 3 hr in clinic Vitals stable Symptoms better   A/P - allergic reaction  Etiology- immune response to covid vaccine possibility of that discussed with patient  Symptoms- SOB, urticaria,hand and facial swelling Joint pain - inflammatory immune response Elevated creatinine - hydration as above. Elevated WBC - due to steroids.  Critical care management as above.   Zyrtec 20 mg bid Continue benadryl 50 mg q 6-8 hr as needed basis only Albuterol prn sob Prednisone 20 mg every day x 3 days, then 10 mg every day x 3 days Side effects discussed with patient  rx of epi pen written for patient. Its uses discussed in detail.  Referral to allergy dept - for follow up and to discuss about second dose of covid vaccine Call 911 if symptoms develop again or worse.  er precautions discussed. Follow up Primary care physician in 24-48 hr. Patient understood all instructions.  5/5 PCP f/u Patient presents for follow up of allergic reaction. Suspect this reaction may have been due ot something she consumed the night before when eating food out rather than the Pfizer vaccine which she had received 8 days prior to the reaction starting. However, she does have appointment with allergy to further discuss this and give formal recommendation on whether she should receive second dose of vaccine. She will continue zyrtec twice a day along with benadryl PRN. Albuterol inhaler sent to different pharmacy along with epi pen. Advised her to continue 20mg prednisone for now untli Friday because her rash did show up in a new place on the back, and she still has some facial swelling. I would be concerned for her reducing the dose before her symptoms start to show improvement. Follow up visit to be scheduled with me on Friday in 2 days, she will inform us if any worsening symptoms. No current anaphylactic symptoms.  5/6 Allergy consult Do not suspect food allergy trigger.   Postpone 2nd covid vaccine dose 2 weeks.  Monitor rash, if resolves in the next week or so, proceed with the second dose.  Stay on zyrtec (cetrizine) now, continue until rash resolved and/or if get 2nd dose, continue for a week after 2nd dose.  If do not get second dose or if similar rash after 2nd dose, requiring prednisone, contact me check antibody titer about a month after finish prednisone.   Continue to avoid tree nuts.    5/7 PCP F/u Patient presents for follow up of allergic reaction that presented one week after receiving Pfizer vaccine. She saw allergist who suspects this is related to vaccine rather than dietary trigger (she has tree nut allergy).   Patient states that the rash in her arms and legs are better. The swelling and puffiness are improved. Just a rash on the neck and back and feet remain that are improving. She is on her last 20mg prednisone then will taper this weekend. Still taking zyrtec twice a day and benadryl every 6 hours as needed for itching.    No further f/u Pt was vaccinated w/ second dose on 5/23 with no indication of reaction in pt chart.