Allergic Reaction /Hives/bee sting /Angioedema

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Symptoms happen after eating .Patient has onset of sensation of throat closing. ”}},{“timeFrame” : {“sentence” : “Onset of symptoms was {ENTRY} ago.”,”label” : “Onset of Symptoms”}},{“checkBoxes” : {“sentence” : “Pain is {ENTRY} in severity.”,”label” : “Pain”,”options” : [{“label” : “Mild”,”value” : “mild”},{“label” : “Moderate”,”value” : “moderate”},{“label” : “Severe”,”value” : “severe”},{“label” : “0”,”value” : “0/10”},{“label” : “1”,”value” : “1/10”},{“label” : “2”,”value” : “2/10”},{“label” : “3”,”value” : “3/10”},{“label” : “4”,”value” : “4/10”},{“label” : “5”,”value” : “5/10”},{“label” : “6”,”value” : “6/10”},{“label” : “7”,”value” : “7/10”},{“label” : “8”,”value” : “8/10”},{“label” : “9”,”value” : “9/10”},{“label” : “10”,”value” : “10/10”}]}},{“checkBoxes” : {“sentence” : “Patient has associated symptoms of {ENTRY}.”,”label” : “Associated Symptoms”,”options” : [{“label” : “Pain”,”value” : “pain”},{“label” : “Diarrhea”,”value” : “diarrhea”},{“label” : “Swelling”,”value” : “swelling”},{“label” : “Redness”,”value” : “redness”},{“label” : “Warmth”,”value” : “warmth”},{“label” : “Bleeding”,”value” : “bleeding”},{“label” : “Abdominal pain”,”value” : “abdominal pain”},{“label” : “Drainage”,”value” : “drainage”},{“label” : “Itching”,”value” : “itching”},{“label” : “Shortness of breath”,”value” : “shortness of breath”},{“label” : “Facial Swelling”,”value” : “facial swelling”},{“label” : “Chest pain”,”value” : “chest pain”},{“label” : “Dizziness”,”value” : “dizziness”},{“label” : “Vomitting”,”value” : “vomitting”}]}},{“checkBoxes” : {“sentence” : “Patient does not have symptoms of {ENTRY}.”,”label” : “Denies Symptoms”,”options” : [{“label” : “Pain”,”value” : “pain”},{“label” : “Diarrhea”,”value” : “diarrhea”},{“label” : “Redness”,”value” : “redness”},{“label” : “Warmth”,”value” : “warmth”},{“label” : “Bleeding”,”value” : “bleeding”},{“label” : “Abdominal pain”,”value” : “abdominal pain”},{“label” : “Drainage”,”value” : “drainage”},{“label” : “Itching”,”value” : “itching”},{“label” : “Shortness of breath”,”value” : “shortness of breath”},{“label” : “Facial Swelling”,”value” : “facial swelling”},{“label” : “Chest pain”,”value” : “Chest pain”},{“label” : “Dizziness”,”value” : “dizziness”},{“label” : “Nausea”,”value” : “nausea”},{“label” : “Vomitting”,”value” : “vomitting”},{“label” : “Vision change”,”value” : “vision change”},{“label” : “Difficulty swallowing”,”value” : “difficulty swallowing”}]}},{“checkBoxes” : {“sentence” : “Patient {ENTRY}.”,”label” : “Exposures”,”options” : [{“label” : “Denies”,”value” : “denies any new exposures”},{“label” : “Pets”,”value” : “reports exposure to pets”},{“label” : “Metals”,”value” : “reports exposure to metals”},{“label” : “Plants”,”value” : “reports exposure to plants”},{“label” : “New Foods”,”value” : “reports exposure to new foods”},{“label” : “Laundry Detergents”,”value” : “reports exposure to new laundry detergent”},{“label” : “Allergens”,”value” : “reports exposure to allergens”},{“label” : “ACE Inhibitor”,”value” : “reports exposure to ACE inhibitor”},{“label” : “New Meds”,”value” : “reports exposure to new medications”}]}},{“checkBoxes” : {“sentence” : “Treatment prior to arrival includes {ENTRY}.”,”label” : “Treatment Prior to Arrival”,”options” : [{“label” : “None”,”value” : “nothing”},{“label” : “Tylenol”,”value” : “Tylenol”},{“label” : “Ibuprofen”,”value” : “Ibuprofen”},{“label” : “Benadryl”,”value” : “benadryl”},{“label” : “Antibiotic Ointment”,”value” : “antibiotic ointment”},{“label” : “EpiPen”,”value” : “epipen”},{“label” : “Steriod Cream”,”value” : “steroid cream”},{“label” : “Ice”,”value” : “ice”},{“label” : “With no significant improvement”,”value” : “with no significant improvement”}]}},{“textArea” : {“sentence” : “{ENTRY}”,”label” : “”,”value” : “Mild swelling of upper and lower lip consistent with angioedema. No lesions. Oropharynx clear. No pharyngeal edema. No drooling or vocal changes. ”}}],”Body”: [{“textArea” : {“sentence” : “{ENTRY}”,”label” : “Physical Exam:”,”value” : “GEN: Well-developed, well-nourished, *** in no acute distress, appears non-toxic HEENT: sclera anicteric, Oral pharynx: Tongue is pink and moist with no swelling. No lip swelling. No posterior oropharynx swelling, uvula midline, no angioedema. No drooling. No vocal changes. Patient is tolerating secretions. NECK: Supple, full ROM CV: regular rate and rhythm LUNGS: lungs clear to auscultation, *** no whizzing, in no respiratory distress ABD: non-distended, non-tender EXT: normal ROM, no swelling NEURO: Alert & oriented. SKIN: intact, warm and dry. ***Mild swelling noted to the. ***There is no visible the stinger. *** Diffuse erythematous blanchable rash. ***An erythematous circular lesion with mild swelling spots noted in ***. There are no vesicles or bullae. ***Hives on the face, no angioedema.***There is swelling and mild redness involving the left infraorbital region and left side of the nose. There appears to be a bee sting site involving the left side of the nose however no visible stinger.  PSYCH: normal mood and effect, calm and cooperative”}},{“textArea” : {“sentence” : “{ENTRY}”,”label” : “”,”value” : “ angioedema: clinic :dexamethasone (DECADRON) tablet 10 mg Route: oral loratadine (CLARITIN) 10 mg tablet famotidine (PEPCID) 20 mg tabletpredniSONE (DELTASONE) 20 mg tablet ”}}],”MDM”: [{“textArea” : {“sentence” : “{ENTRY}”,”label” : “”,”value” : “Pstient  has a swollen left great toe following a bee sting. This is likely representing a local allergy given recent onset. Recommend ice, and elevation primarily. Discussed Benadryl as needed at home. Patient was given single dose of dexamethasone, 4 mg. Discussed warning signs of infection and indications for urgent reevaluation. Parent comfortable with the plan. There is no airway involvement nor difficulty swallowing. Patient well/non-toxic appearing. No evidence of shock. The patient is tolerating fluids. Findings are minimal and there was no progression of symptoms during UC course.*** Given epinephrine intramuscularly which, the patient stated they felt improved. ***Patient was given Benadryl and dexamethasone and had an improvement in symptoms. Upon reassessment swelling has improved and reports feeling better. *** . Monitored for a period of *** minutes. Patient was discharged home in stable condition. Discussed advancement of fluids as tolerated. patient was instructed to avoid potential precipitating factor. The patient is to follow up with the primary care provider to further discuss anaphylactic treatment and allergen testing as needed. Educated patient on signs and symptoms of anaphylaxis. Go to emergency department urgently if new or worsening symptoms develop including oral swelling, difficulty breathing, chest pain, shortness of breath, worsening rash, headache, or other worrisome symptoms. ***added to allergy list. ** Stings was identified and removal was indicated. *** 2 epinephrine autoinjector was ordered. I Instructed patient on how and when to use epinephrine. Advised to fill the prescription immediately and carry epinephrine at all times. Patient is here for evaluation of facial swelling and redness following a bee sting. The symptoms started shortly after the bee sting, therefore, I suspect that this is an allergy and not cellulitis. There is no symptoms suggesting anaphylaxis. Given the swelling in the local area, I suspect this is a local allergy and not a systemic allergy. Patient was given Benadryl and dexamethasone. will be prescribed prednisone to start tomorrow. Recommended cool compresses, and discussed warning signs that would warrant urgent reevaluation. Discussed that if there is no improvement within the next 24 hours, repeat exam recommended.   Patient here for lip swelling. Findings on exam consistent with angioedema, however uncertain etiology. Recommended treating with antihistamines and steroids. She was prescribed prednisone, loratadine, Benadryl, and Pepcid. She is given a dose of dexamethasone. Patient is stable for discharge. Her symptoms been present for several weeks. Recommended PCP follow-up. Patient was provided information for indications warranting emergent reevaluation such as shortness of breath or difficulty swallowing.”}},{“checkBoxes” : {“sentence” : “Treatments provided included {ENTRY}.”,”label” : “Treatments Provided”,”options” : [{“label” : “Benadryl”,”value” : “benadryl”},{“label” : “Vistaril”,”value” : “vistaril”},{“label” : “*Dexamethasone (aka DECADRON) 1 mg/mL oral syringe 10 mg”,”value” : “*dexamethasone (aka DECADRON) 1 mg/mL oral syringe 10 mg”},{“label” : “Prednisone”,”value” : “prednisone”},{“label” : “Cetirizine (Zyrtec)”,”value” : “Cetirizine (Zyrtec)”},{“label” : “Loratadine (Claritin)”,”value” : “Loratadine (Claritin)”},{“label” : “Famotidine (Pepcid)”,”value” : “Famotidine (Pepcid)”},{“label” : “Ranitidine (Zantac)”,”value” : “Ranitidine (Zantac)”},{“label” : “Epinephrine”,”value” : “epinephrine”},{“label” : “Ambulatory Referral to Swedish Alllergy and Immunology “,”value” : “ambulatory Referral to Swedish Alllergy and Immunology “},{“label” : “W/O Improvement”,”value” : “without improvement in symptoms”}]}},{“textArea” : {“sentence” : “{ENTRY}”,”label” : “”,”value” : “in kids with bee stings: dexamethasone, 4 mg BenadrylRecommend ice, and elevation primarily. ”}},{“checkBoxes” : {“sentence” : “Patient prescribed {ENTRY}.”,”label” : “Prescribed (Steroids and other)”,”options” : [{“label” : “*Dexamethasone (aka DECADRON) injection 10 mg”,”value” : “*dexamethasone (aka DECADRON) injection 10 mg”},{“label” : “*PredniSOLONE (AKA PRELONE) 15 mg/5 mL Oral Solution”,”value” : “*predniSOLONE (AKA PRELONE) 15 mg/5 mL Oral Solution”},{“label” : “Diphenhydramine 25 to 50 mg IV (“,”value” : “diphenhydramine 25 to 50 mg IV (“},{“label” : “For oral second-generation H1 antihistamines (eg, cetirizine) offer certain advantages over first-generation agents”,”value” : “for oral second-generation H1 antihistamines (eg, cetirizine) offer certain advantages over first-generation agents”},{“label” : “Ranitidine (Zantac) 50 mg IV”,”value” : “Ranitidine (Zantac) 50 mg IV”},{“label” : “Loratadine (Claritin)”,”value” : “Loratadine (Claritin)”},{“label” : “Famotidine (Pepcid)”,”value” : “Famotidine (Pepcid)”},{“label” : “Methylprednisolone 125 mg IV.in kids 1 mg/kg (max 125 mg) IV.”,”value” : “methylprednisolone 125 mg IV.in kids 1 mg/kg (max 125 mg) IV.”},{“label” : “In kids EPINEPHrine (EPIPEN JR) 0.15 mg/0.3 mL Inj Auto-Injector”,”value” : “in kidsEPINEPHrine (EPIPEN JR) 0.15 mg/0.3 mL Inj Auto-Injector”},{“label” : “Albuterol (AKA VENTOLIN HFA) 90 mcg/actuation Inhl HFA Aerosol Inhaler”,”value” : “albuterol (AKA VENTOLIN HFA) 90 mcg/actuation Inhl HFA Aerosol Inhaler”},{“label” : “Clindamycin palmitate (AKA CLEOCIN) 15 MG/ML Oral Recon Soln”,”value” : “clindamycin palmitate (AKA CLEOCIN) 15 MG/ML Oral Recon Soln”},{“label” : “*cetirizine 10 mg”,”value” : “*cetirizine 10 mg”},{“label” : “Medrol Dosepak”,”value” : “medrol Dosepak,”},{“label” : “Ranitidine 75 mg”,”value” : “ranitidine 75 mg”},{“label” : “Singulair 10 mg”,”value” : “singulair 10 mg”}]}},{“checkBoxes” : {“sentence” : “{ENTRY}.”,”label” : “Follow Up”,”options” : [{“label” : “We recommend epinephrine for patients with apparently mild symptoms and signs (eg, a few hives and mild wheezing). Give epinephrine .03 to .05 intramuscularly, preferably in the mid-outer thigh hold for 3 seconds. children weighing less than 25 kg should receive the 0.15 mg dose, and those weighing over 25 kg should receive the 0.3 mg dose every 5 to 15 minutes or more Ma x3 does. Place patient in recumbent position, if tolerated, and elevate lower extremities. Oxygen: Give 8 to 10 L/minute via facemask or up to 100% oxygen, as needed. Normal saline rapid bolus: Treat hypotension with rapid infusion of 1 to 2 liters Albuterol (salbutamol): For bronchospasm resistant to IM epinephrine, give 2.5 to 5 mg in 3 mL albuterol via nebulizer. Repeat, as needed. Adjunctive therapies: H1 antihistamine*: diphenhydramine 25 to 50 mg IV (for relief of urticaria and itching only). in kids 1 mg/kg (max 40 mg) IV. for oral second-generation H1 antihistamines (eg, cetirizine) offer certain advantages over first-generation agents .H2 antihistamine: ranitidine 50 mg IV. in kids 1 mg/kg (max 40 mg) IV Glucocorticoid*: Consider giving methylprednisolone 125 mg IV.in kids 1 mg/kg (max 125 mg) IV.if they respond well to other approtch steroid is not good but if they have asthma and still wheezing steroid is good. observation period of at least four hours from the last intramuscular (IM) dose of epinephrine for patients at risk for severe anaphylaxis (ie, asthma, those for whom more than one dose of epinephrine was required to treat the initial reaction, or if symptoms persist). four hours of observation is safe in select populations (ie, children treated for anaphylaxis without complications and discharged with an 2 epinephrine autoinjector.”,”value” : “we recommend epinephrine for patients with apparently mild symptoms and signs (eg, a few hives and mild wheezing). Give epinephrine .03 to .05 intramuscularly, preferably in the mid-outer thigh hold for 3 seconds. children weighing less than 25 kg should receive the 0.15 mg dose, and those weighing over 25 kg should receive the 0.3 mg dose every 5 to 15 minutes or more Ma x3 does. Place patient in recumbent position, if tolerated, and elevate lower extremities. Oxygen: Give 8 to 10 L/minute via facemask or up to 100% oxygen, as needed. Normal saline rapid bolus: Treat hypotension with rapid infusion of 1 to 2 liters Albuterol (salbutamol): For bronchospasm resistant to IM epinephrine, give 2.5 to 5 mg in 3 mL albuterol via nebulizer. Repeat, as needed. Adjunctive therapies: H1 antihistamine*: diphenhydramine 25 to 50 mg IV (for relief of urticaria and itching only). in kids 1 mg/kg (max 40 mg) IV. for oral second-generation H1 antihistamines (eg, cetirizine) offer certain advantages over first-generation agents .H2 antihistamine: ranitidine 50 mg IV. in kids 1 mg/kg (max 40 mg) IV Glucocorticoid*: Consider giving methylprednisolone 125 mg IV.in kids 1 mg/kg (max 125 mg) IV.if they respond well to other approtch steroid is not good but if they have asthma and still wheezing steroid is good. observation period of at least four hours from the last intramuscular (IM) dose of epinephrine for patients at risk for severe anaphylaxis (ie, asthma, those for whom more than one dose of epinephrine was required to treat the initial reaction, or if symptoms persist). four hours of observation is safe in select populations (ie, children treated for anaphylaxis without complications and discharged with an 2 epinephrine autoinjector.”},{“label” : “Anaphylaxis Emergency Action Plan”,”value” : “anaphylaxis Emergency Action Plan”},{“label” : “Food Allergy and Anaphylaxis Emergency Care Plan”,”value” : “food Allergy and Anaphylaxis Emergency Care Plan”},{“label” : “For discharge give 2 Epipen, cetirizine and ranitidine and Prednisone in asthma”,”value” : “for discharge give 2 Epipen, cetirizine and ranitidine and Prednisone in asthma”},{“label” : “If you see hoarseness, generalized hives, angioedema, flushing, pruritus, wheezing give Epipen”,”value” : “if you see hoarseness, generalized hives, angioedema, flushing, pruritus, wheezing give Epipen”},{“label” : “EPINEPHrine (aka ADRENALIN) injection 300 mcg”,”value” : “ePINEPHrine (aka ADRENALIN) injection 300 mcg”},{“label” : “Bee sing: in clinic; diphenhydrAMINE (BENADRYL) tablet 50 mg and dexamethasone (DECADRON) tablet 8 mg”,”value” : “bee sing: in clinic; diphenhydrAMINE (BENADRYL) tablet 50 mg and dexamethasone (DECADRON) tablet 8 mg”},{“label” : “In kids:dexamethasone (DECADRON) 4 mg/mL injection 5 mg”,”value” : “in kids:dexamethasone (DECADRON) 4 mg/mL injection 5 mg”},{“label” : “DiphenhydrAMINE (BENADRYL) capsule 25 mg “,”value” : “diphenhydrAMINE (BENADRYL) capsule 25 mg “},{“label” : “EPINEPHrine auto-injector 0.15 mg/0.3 mL injection”,”value” : “ePINEPHrine auto-injector 0.15 mg/0.3 mL injection”},{“label” : “Epinephrine 0.3 mg IM given via EpiPen. Followed by Solu-Medrol 125 mg IM. Epinephrine was given by me after the area right lateral thigh was prepped with alcohol.”,”value” : “epinephrine 0.3 mg IM given via EpiPen. Followed by Solu-Medrol 125 mg IM. Epinephrine was given by me after the area right lateral thigh was prepped with alcohol.”}]}}]}