Yesterday 08/15/2006 Pneumovax was administered in mid left deltoid at about at about 11:30 am.  By afternoon perhaps 4 hours later she noticed there was a slight swelling and discomfort just distal to the site of injection.  She goes to bed at 6:30 and wakes up at 2:30 in the morning, this morning when she awoke at 2:30 am as usual, she noticed there was further swelling and a pink warm discomfort for an inch or so distal to the site of injection in left upper arm.  Wore a sweater all day and thought nothing more of it until she came home at 2:30 this afternoon, took off her sweater, took off her sweater, and noticed that there was a rash that felt warm and had spread uniformly down to just proximal to left popliteal fossa covering the entire biceps and lateral upper arm.  This has a moderately burning and itching sensation.  There is also some soreness in left anterior shoulder region.  She has full sensation and no loss of strength of function in the arm.  She has no spread of inflammation proximal to the site of injection.  There is no shortness of breath or wheezing, no fever or sweating, no lightheadedness, or other systemic symptoms.  She has never previously had an adverse reaction to any immunization. Patient active problem list: family history breast malignant (V16.3), personal history colonic polyps- colonscope in 2001, repeat in 5 years, family history gastrointestinal malignancy (V16.0), hemorrhoids not otherwise specified (455.6), malignant melanoma leg (172.7), rectal and anal hemorrhage (569.3). General appearance alert, cooperative, no acute distress. blood pressure 124/68, temperature 98.2 (Tympanic), weight 125 pounds 8.0 oz (56.926 kilograms) Last menstrual period hysterectomy.  Neck- neck supple.  No adenopathy, mass or bruit.  Thyroid normal.  Lymph nodes-none palpable in neck or supraclavicular region on the left.  Left arm-shows the entire surface of skin starting at of biceps down to popliteal fossa and laterally to mid lateral upper arm covered with warm uniform rash which blanches to pressure, there are no papules or regional macules in the zone of allergic inflammation, there is a distinct boundary at the edge of the whole inflamed region, but the skin is not raised as much as would be expected in hives.  In left anterior shoulder where the rash does not reach, there is some slight soreness in her lateral pectoral muscle near where it attached to the humerus, but no local swelling or evidence of injection.  Exam of antecubital and axillary fossa are without tenderness or lymph node swelling.  Lungs entirely clear to auscultation of anterior and posterior fields bilaterally.  Known potential drowsy side effect to some medications (surmise possibly BENADRYL).  Discussion: she is informed this is an adverse reaction to the injection yesterday, not an expected effect.  Treatment strategy of risk and benefit of just antihistamines versus administering prednisone is reviewed.  Since prednisone use could undermine immunological benefit, will not use it at this point.  Will treat now with just antihistamines, states she is sensitive to sedative effect of antihistamines and prefers to minimize this.  Taking this intro account: she is given 10 samples of Alavert (loratadine 10 mg) to use one now and one every 12 to 24 hours. I suggest also BENADRYL 25 mg when she gets home and goes to bed she thinks will be in 1 hour, when sedative side effect would be ok during sleep.  When she gets up at 2:30 in the morning to get ready for work, take another Alavert 10 mg.  She may take this up to every 12 hours, if benefits wears off, through standard benefit is up to 24 hours. She may use BENADRYL 25 also up to every 4-6 hours though this may result in sedation for her.  She is informed there is a small chance this could spread further into her chest or lung system, in which case if she becomes short of breath at all, she should go immediately to urgent care center or emergency room (in which case the benefit of PREDNISONE or equivalent would outweigh any disadvantage).  We do not expect this to happen, but she is alerted how to respond in the event that it does so after hours.  Also, if area of rash extends below (it has been moving distally, not proximally) let us know.