Patient walking into immunization clinic for reevaluation of rash that seems to be getting worse for 2-3 days.  Now with lesions on abdomen, inner arms,and thighs.  Positive for pruritus, has stopped ZYRTEC and ATARAX secondary to increase drowsiness.  No fever, cough, nausea, vomit, diarrhea.  Did note sharp chest pain today but no associated dyspnea on exertion, palpitation, orthopnea, post nasal drip, diaphoresis or shortness of breath, lasted only seconds not associated with exertion.  No acute distress versus deferred patent in no acute distress bilateral liver lesions to upper aspect of legs now seen a little       right inner thigh with some      abdomen, arms papular like lesions without discharge.  Right deltoid 3-4 centimeter of salmon colored non tender discoloration surrounding vaccine site with a 4-5 millimeter linear crescent shape similar streak.   Case discussed with doctor, contacted doctor , forwarded photos and discussed case.      with consecutive measure discussed.  Recommends covering the right inner thigh area just in case there has been acute inoculation, but discussed with mainly a hypersensitivity type reaction due to the medically dermatitis.  No antibiotics or vaccinia immune globulin recommended. Rhus dermatitis/small pox vaccine, lymphangitis, reassurance, observe, will forward , follow up if symptoms increase or changes.  26-July-2006 16:15 contacted patient for a follow up phone call.  He states today he is feeling better.  Right deltoid area crescent shaped lymphangitis resolved today, lesions continues to scab up. No further symptoms of chest pain.  Follow of changes. Patient presents for follow up on rash to bilateral lower extremities.  He has been using ZYRTEC and ATARAX which is helping the itching but making him very tired.  No new lesion and lesion to left ankle   improved.  no    . Vaccine site also doing well. No acute distress versus deferred. Bilateral lower edema, no new lesion, crusting area has started to fall off from left ankle. Linear lesions not as angry.  No lesion bone thigh area. Vaccine site with 3-4 millimeter vesicle with 2-3 millimeter of surrounding  erythema, no discharge, swelling or heat. Rhus dermatitis/small pox vaccine continue with conservative measures, avoid scratching, followup if signs and symptoms increases or changes, otherwise as needed. Patient walked into immunization clinic after small pox vaccine 14 July.  Patient states he started with rash below lower quarter aspect of thigh down to feet for 2-3 days very pruritic.  Small pox vaccine site covered and non pruritic.  Patient was scratching hard to ankle area and caused it to bleed 2 days ago.  Patient also states he had been hicking in the woods about 10 days ago with shorts and sandals. No fever, cough, nausea, vomit, diarrhea, and no other skin lesions above thighs. No acute distress versus deferred, bilateral lower extremities with a few linear vesicular lesions and some crusting left ankle area with dry blood scabs lesions irregular shaped, few slightly raised wheals, right deltoid with and without erythema, swelling, tender to pressure or discoloration.  Rhus dermatitis, doubt vaccination or allergic reaction, patient education, avoid scratchy, ZYRTEC 10mg every day for itching 30 tablets no refill, ATARAX 25mg every night when needed 30 tablets no refill, consider oral steroids, picture taken, follow up in 2 days to immunization clinic to reevaluate       if signs and symptoms increases or change.