Page History

A physician sees a patient in clinic for routine outpatient care.  Recently the patient was prescribed penicillin V 500 mg orally two times daily x 10 days for streptococcal pharyngitis. He tells the physician that he has developed hives the previous week and on examination, the physician confirms the presence of generalized hives. He records this in the patient record as an Observation.

A review of systems fails to reveal any other causes and the physician believes that the patient may be having an urticarial reaction to penicillin. He has lingering uncertainty about this and tells the patient to stop the penicillin and employ diphenhydramine for relief. He schedules him back in a week for follow-up and when recording his note for the visit, he adds to his assessment in the problem list: “Moderate urticarial reaction, possible penicillin allergy”.

A week later, the patient returns for follow-up with the itching and rash entirely resolved.  He reports that the reaction subsided within days after stopping the penicillin.  The physician adds “Penicillin allergy probable: moderate reaction of hives; criticality unable-to-assess” to the allergy list.