MDM - Allergic Reaction (Rash)

[##]-year-old [male/female] with [rash/throat swelling/etc.] with history and exam consistent with likely allergic reaction to [allergen/unknown precipitant].

Initial consideration in this patient included allergic reaction, anaphylaxis, angioedema, Stevens-Johnson, toxic epidermal necrolysis, and infectious etiologies among others.

Patient presented with [describe symptoms] concerning for allergic reaction.  Patient noted to have no evidence of anaphylaxis on presentation given absence of severe symptoms or involvement of 2 or more symptoms.  Patient noted to have rash consistent with urticaria [to the location/diffusely].  No evidence of mucosal involvement, desquamation, fever, or other findings suggestive of Stevens-Johnson, toxic epidermal necrolysis, or infectious rash.  Patient noted to have no swelling of the lips, tongue, or throat suggestive of angioedema at time of ED evaluation.  Patient noted to have no wheezing, cough, or other respiratory symptoms at time of ED evaluation.  Patient treated with Diphenhydramine (H1 antagonist), [Famotidine/Ranitidine] (H2 antagonist) [and corticosteroid] with noted improvement.

Patient [reported/denied] a history of similar episodes of allergic reaction in the past [to specify/an unknown allergen].  Patient was counseled on return precautions for evidence of more severe allergic reaction or evidence of anaphylaxis.

Prior to discharge, we discussed return precautions, specifically for evidence of recurrent allergic symptoms, treatment [with antihistamine/steroid], and follow up with primary care doctor within [2-3 days/1 week] for further evaluation, and the patient demonstrated understanding and agreement.

Patient was prescribed an intramuscular epinephrine auto-injector at time of discharge with instructions in the ED about appropriate use.  We specifically emphasized that this medication was for life-threatening emergencies, and any use required return to the ED, and the patient demonstrated understanding and agreement.

https://www.epipen.com/-/media/files/epipen/howtouseepipenautoinjector.pdf