Associated Diagnoses:   None  Basic Information  Time seen: Date & time 10/05/2013 13:38:00.  History of Present Illness  Patient is a previously healthy 22 year old who presents to our ED after she received her flu vaccination. She received Benadryl 50 mg x1 before coming down to the ED. Initially, she developed rash and pruritis and while in the ED developed diffculty breathing and worsening of the erythema rash on her chest. Mild nausea, positive lightheadedness, facial numbness, no vomiting. Last time had po intake was coffee this morning  Review of Systems  Negative unless stated in HPI  Health Status  Allergies:  Allergic Reactions (Selected) Hospital Admission: Severe Influenza Virus Vaccine- No reactions were documented.  Medications:  (Selected).  Inpatient Medications Ordered ZANtac: 50 mg, IV, 1 time only epinephrine for anaphylaxis: 0.3 mg, IM, 1 time only  Immunizations: Up to date.  Past Medical/ Family/ Social History  Medical history  Skin/allergy: had rash 2 years ago with flu vaccination, no issues last year with flu vaccination.  Surgical history: Reviewed - no surgical history Family history: Reviewed - no significant family history  Social history: Nurse here.  Physical Examination  Vital signs: Vital Signs,   10/05/2013 13:25 CDT Temperature Celsius 35.7 DegC  LOW  Temperature Route Oral   Heart Rate 95 bpm  Respiratory Rate 20 BR/min  Systolic Blood Pressure Cuff Monitored 125 mmHg  Diastolic Blood Pressure Cuff Monitored 90 mmHg  NBP Cuff Sizes Adult   NBP Extremity Arm, left   NBP Position Lying   NBP Activity Calm   SpO2 100 % Measurements.  10/05/2013 13:27 CDT     Current Weight            61.80 kg    General:  Alert  Skin:  erythematous rash on chest  Eye:  Extraocular movements are intact  Cardiovascular:  Tachycardic  Respiratory:  Lungs are clear to auscultation.  respirations are non-labored.    Neurological:  Alert.  normal speech observed.    Psychiatric:  Cooperative  Medical Decision Making  Differential Diagnosis:  22 year old with anaphylaxis type symptoms after receiving flu vaccination.  Orders  Pharmacy: epinephrine for anaphylaxis (Order): 0.3 mg, IM, 1 time only (Selected),   Inpatient Orders Ordered ZANtac: 50 mg, IV, 1 time only Completed Solu-MEDROL: 125 mg, IV, 1 time only epinephrine for anaphylaxis: 0.3 mg, IM, 1 time only epinephrine for anaphylaxis: 0.3 mg, IM, 1 time only normal saline fluid bolus: 1 L, IV, 1 time only (Selected) Inpatient Orders Completed epinephrine for anaphylaxis: 0.3 mg, IM, 1 time only  Reexamination/ Reevaluation  Re-examination/Re-evaluation:  Notes After epinephrine x2, Solu-medrol, Zantac, and Benadryl arm pruritis is improving. Still coughing, and throat is still "itchy" Re-examination/Re-evaluation:  Time  10/05/2013 14:20:00, Notes Still having cough, and throat is itchy. Will give third dose of epinephrine and transfer via ambulance for continued observation Re-examination/Re-evaluation:  Time  10/05/2013 14:27:00, Assessment Still with cough, scratchy throat and hives, although pt. now perceives these symptoms to be improved Impression and Plan  Anaphylaxis (66382015, Discharge, Medical/Surgical)  ED Discharge Plan  Counseled: Patient, Regarding diagnosis, Regarding treatment plan, Regarding prescription.   Condition: Fair.   Disposition Order  Patient Care: Transfer patient (Order): 10/05/2013 14:27 CDT, Condition: Fair, Transfer to another This note is preliminary until signed below by the supervising provider.   Will transfer to another hospital for continued observation  Attending Evaluation Agreement  Teaching-Supervisory Addendum-Brief  I personally performed: supervision of the patient's care, the medical history, the physical exam, the medical decision making.  The case was discussed with: the resident.  Evaluation and management service: I agree with the evaluation and management decisions made in this patient's care as documented in the note above.  Any exceptions are documented in my note below..  Attending Pertinent History  History per above  Attending Physical Exam  Vital signs: Per nurse's notes.  General:  Alert.  cooperative.  contant cough Skin:  Warm.  dry.  pink.  intact.  normal for ethnicity.  urticarial rash on trunk Head:  Normocephalic.  atraumatic.    Neck:  Supple.  no lymphadenopathy.    Eye:  Pupils are equal, round and reactive to light.  extraocular movements are intact.  normal conjunctiva.    Ears, nose, mouth and throat:  Oral mucosa moist.  No pharyngeal erythema or exudate.    Cardiovascular:  Regular rate and rhythm.  No murmur.  No gallop.  Normal peripheral perfusion.    Respiratory:  Lungs are clear to auscultation.  respirations are non-labored.  breath sounds are equal.  Symmetrical chest wall expansion.    Gastrointestinal:  Soft.  Nontender.  Non distended.  Normal bowel sounds.  No organomegaly.    Neurological:  No focal neurological deficit observed  Attending Summary/Plan  Pt is an employee, RN who had hives, difficulty breathing, cough, stratchy throat, some light headedness which started ~ 10 -15 minutes after getting IM Influenza shot.  Pt. received po Benadryl while on the clinic floor she works on, then transfer to the ED.  Pt. then received 3 IM 0.3 mL doses of epinephrine with some improvement of the throat symptoms, but continues with irritant cough and hives. Pt never had documented hypotension.  Pt. also received 125 mg Solumedrol IV, 50mg Zantac IV and given NS.  Plan to send to adult ER for further observation.