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

Discharge Instructions - Shingles

As discussed in the Emergency Department prior to discharge, you have been diagnosed with shingles.  If you have been diagnosed with shingles, you likely had chicken pox when you were a child.  The virus that caused chicken pox never actually leaves the body; it hides, or "sleeps" inside the spinal cord.  For most people, the virus stays quiet inside the spinal cord and never reactivates or "wakes up."  However, for 1 in 5 people (about 20 percent of people), the virus does reactivate.  It travels down one of the nerves from the spinal cord, causing the rash to appear along the path of that nerve.  This usually causes a burning pain to the area, then a skin rash appears a few days later.

To control your pain, start with Ibuprofen (also known as Advil or Motrin) or Naproxen (also known as Aleve).  An hour after you’ve taken one of them, if it still hurts too much to take a deep breath, you can add a stronger pain medication.  You may have been prescribed a stronger pain medication such as Hydrocodone (Norco) or Oxycodone (Percocet).  These stronger medications can make you drowsy, so DO NOT DRIVE OR OPERATE MACHINERY WITHIN 8 HOURS OF TAKING THEM.  These medications usually also cause constipation, so take an over-the-counter medicine for constipation, such as Metamucil or Docusate, at the same time as taking these medications.

For a small number of patients, the pain lasts more than a month (even after the rash is gone).  This is called “post-herpetic neuralgia.”  See your primary care provider if this is the case for you.

If you have been prescribed an anti-viral medication, start it as soon as possible and complete the entire course (do not stop taking it early).  If you have been prescribed a steroid medication, start it as soon as possible and complete the entire course (do not stop taking it early).

Remember that you are contagious while you have the skin rash.  The risk is that you can give another person chicken pox if they haven’t had chicken pox before; however, you can’t give them shingles.

Specifically avoid contact with the following people:

    -Pregnant women

    -People who are taking chemotherapy

    -Anyone who has not had chicken pox or has not been vaccinated against chicken pox

The skin rash is no longer contagious when the bubbles have popped and dried over.  You can put a bandage and/or lots of layers of clothing on top of the bubbles to try to prevent spreading the virus.

If the rash is itchy, you can apply chamomile lotion or try oatmeal baths.  Keep the skin rash clean and dry as best as you can.  It usually lasts 2-4 weeks.

Monitor your rash daily.  If the rash is getting redder in the surrounding skin, it may be becoming infected.  If so, you will need to get antibiotics from your primary care provider or the Emergency Department.

See your primary care provider within 1-2 weeks.  If the rash is on your forehead, you will need to follow-up with an Ophthalmologist (an eye doctor) as well, as the eye can be affected in this area, particularly if the rash is also on the end of the nose.

Return to the Emergency Department for rash spreading to the other side of the body, or to another area of the body, fever (≥38.0 °C or 100.4 °F), confusion, or any new or concerning symptoms.

MDM - Mastitis

[##]-year-old [breastfeeding] female with [redness/irritation/swelling] of the [right/left/bilateral] breast(s) with history and exam consistent with likely mastitis.

Initial considerations in this patient included mastitis, cellulitis, mechanical irritation of the breast, systemic infectious processes, and necrotizing soft tissue infections among others.

Patient presented with [erythema/swelling/tenderness] of the [right/left/bilateral] breast with associated [fever/chills/flu-like symptoms] concerning for mastitis [in the setting of breastfeeding].  Labs [were/were not] obtained in the evaluation of this patient [based on absence of response to antibiotics after 2 days, recurrent episode of mastitis, hospital acquired mastitis, reported allergy to standard antibiotic therapy, or severe or unusual case/absence of concerning features].  [Labs were noted to be unremarkable/notable for specify.]  A [bedside/formal] ultrasound was obtained with [no evidence of concurrent abscess/evidence of superficial/deep abscess measuring ## cm].  [Given superficial/deep nature of abscess, a needle aspiration was performed under ultrasound guidance/surgery was consulted for further management.]

[The site of cellulitis was marked prior to discharge from the ED with strict return precautions given for evidence of worsening infection.]  We discussed return precautions, specifically for evidence of worsening infection, treatment with [Dicloxacillin/Cephalexin/Clindamycin/Augmentin] and symptomatic treatment, and follow up with primary care doctor within 2-3 days for further evaluation of response to therapy, and the patient demonstrated understanding and agreement.  Prior to discharge, we emphasized the importance of continuing to breastfeed while on antibiotics, and the patient demonstrated understanding and agreement with this recommendation.

Discharge Instructions - Dermatitis

As discussed in the Emergency Department prior to discharge, you have been diagnosed with dermatitis.  Dermatitis is a type of skin rash that can happen after your skin touches something that irritates it or something you are allergic to.

Things that irritate the skin can be found in products you use every day, such as soaps or cleansers.  

Some of the things that can cause skin allergies include:

    -Certain medicines, perfumes, or cosmetics

    -The metal in some kinds of jewelry

    -Plants, such as poison ivy and poison oak

Sometimes you can develop a rash the first time you touch something.  But it is also possible to get a rash from something you have used before without any problems.

If you have a rash, your skin might be red, dry, itchy, or cracked.  If your rash is caused by an allergy, you might also have some swelling or blisters where you have the rash.

Severe symptoms include:

    -Pain

    -Widespread swelling

    -Blisters, oozing, or crusting of the skin

When you have dermatitis, you should:

    -Avoid using or touching whatever might have caused your rash

    -Protect your skin from anything that might irritate it or cause an allergy (wear gloves).

    -Try using soothing skin products to help with the itching and discomfort.

Things that might help with rash include:

    -Unscented, thick moisturizing cream or petroleum jelly

    -A special kind of bath called an oatmeal bath

In the Emergency Department you may have been prescribed:

-Steroid creams and ointments – These are not the same as the steroids some athletes take illegally.They go on the skin, and they relieve itching and redness.

-Steroid pills – You might need to take these for a short time if your rash is severe.  But your doctor or nurse will want to take you off steroid pills as soon as possible.  Even though these medicines help, they can also cause problems of their own.

-Wet or damp dressings – These can be helpful for skin that is crusting or oozing.  To use a wet or damp dressing, you will need to wear 2 layers of clothing.  First, you put on a layer of damp cotton clothes over your rash.  Then, you put on a layer of dry clothes on top of the damp ones.  People who need these dressings often wear them at night when they sleep.

Return to the Emergency Department if you develop a fever (≥38.0 °C or 100.4 °F), your rash worsens, or you develop any other new or concerning symptoms.

MDM - Shingles

[##]-year-old [male/female] with [rash/burning pain to the location] with history and exam consistent with likely herpes zoster (shingles).

Initial considerations in this patient included varicella zoster virus reactivation (shingles), bullous pemphigoid, primary varicella, contact dermatitis, disseminated gonoccal disease, and other infectious and non-infectious etiologies of rash amongst others.

Patient presents with [maculopapular/vesicular] rash to the [location] in a dermatomal distribution that does not cross the midline suggestive of shingles.  Patient describes [current/antecedent] pruritus, paresthesia, and pain consistent with shingles.  Patient [reports/denies] history of prodromal symptoms [describe headache, malaise/etc.].  [Patient noted to have rash to the face without evidence of eye pain or redness, involvement of the tip of the nose (Hutchinson’s sign), or other findings suggestive of ophthalmic involvement (herpes ophthalmicus).]  [Patient noted to have no evidence of vesicular lesions to the tympanic membrane to suggest otic involvement (Ramsey-Hunt syndrome).]  Patient [noted to be/reports being] up to date on vaccinations including for varicella.  No evidence of disseminated rash, severe disease, or systemic symptoms to suggest immunocompromise in this patient.

Prior to discharge, we discussed analgesia with [NSAIDs/opiodis/Gabapentin] and Diphenhydramine for pruritis.  We discussed starting [Acyclovir/Valacyclovir] antiviral treatment [given presentation les than 72 hours from onset of rash and likely benefit/despite lower likelihood of benefit given presentation over 72 hours from the onset of rash given low risk of harm from this treatment].  Glucocorticoids [were/were not] given at this time after consideration and discussion with the patient of limited evidence of benefit and potential harms of this treatment (such as hyperglycemia and transient immunocompromise). 

We discussed return precautions and recommended follow up with primary care provider within one week, and the patient demonstrated understanding and agreement with this plan.