Medication reaction

Template

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Suspected medicationChoose oneFirst line

ReactionChoose one

Red flags presentChoose any

Red flags absentChoose any

Current courseChoose one

Allergy listChoose one

AntihistamineChoose any

SteroidChoose any

AlternativesChoose any

ReferralChoose one

DispositionChoose one

Follow-upChoose one

Counseling paragraphChoose oneParagraph

CounselingNot in the note with these choices

Discussed the need for emergency evaluation today. Caregiver expressed understanding and agreement with plan. Answered all questions.

Note when inserted as is

Medication reaction
• Rash after several days of the medication without other symptoms, consistent with a benign delayed reaction
• No mouth or eye sores, blistering or peeling skin, skin pain, lip or facial swelling, trouble breathing, or joint swelling
• Stopped the medication
• Added to the allergy list as a suspected reaction; an allergy evaluation can clarify whether it is safe to use again
• Recommended zyrtec or benadryl as needed for itching or hives
• Follow up as needed

Rashes that start after several days of an antibiotic are common and are rarely a true allergy, and the rash usually fades over several days. Recommended supportive care with an emphasis on gentle skin care, cool compresses, and zyrtec or benadryl for itching. Return precautions given including trouble breathing, facial or lip swelling, vomiting, spreading hives, mouth or eye sores, skin pain, blistering, fever, worsening rash, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions.

What the sources cover

Suspected medication (common antibiotics)
Reaction type: delayed benign rash, immediate hives, serum sickness-like, side effect, severe (SJS, DRESS)
Red flags present or absent (mucosal sores, blistering, skin pain, facial swelling, breathing, joint swelling)
Course: stopped, completed, switched, okay to finish
Allergy list: suspected, low risk not listed, side effect, allergy, delabeled
Later-generation cephalosporins safe
Allergy referral; referral if unclear; in-office amoxicillin challenge
Paragraph per branch; ED closing

Used to decide, kept out of the note

Penicillin skin testing, serum IgE

Return precautions in the template

trouble breathingfacial or lip swellingvomitingspreading hivesmouth or eye soresskin painblisteringfeverworsening rash

Sources

Few formal guidelines cover this topic, so the template also leans on expert opinion.