Drug hypersensitivity: questionnaire Special article

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$Prueba de uso con guante de látex como método de diagnóstico ...$

ANEXO. Drug hypersensitivity (cont.) Drug hypersensitivity: questionnaire GASTROINTESTINAL AND RESPIRATORY SYMPTOMS: ASSOCIATED SYMPTOMS: Cough Edema Location/s:............................................ Dysphonia Pain/Burning Location/s:............................................ Dyspnea PEFR or FEV1:...................................... Arthralgia/Myalgias Location/s:............................................ Wheezing/Bronchospasm Lymphadenopathy Other/Specification:............................................................... Rhinitis CARDIOVASCULAR SYMPTOMS: Rhinorrhea Tachycardia Pulse: ............./min. Sneezing Hypotension Blood pressure: ............................mmHg Nasal obstruction Collapse Other/Specification:........................................................................ PSYCHIC SYMPTOMS: Arrhythmia Other/Specification: ............................................................... Fear/Panic reaction Vertigo INVOLVEMENT OF OTHER ORGANS: Fainting (e.g. periphearal neuropathy, lung involvement, cytopenia, etc.) Paraesthesia/Hyperventilation ....................................................................................... Sweating .......................................................................................... Other/Specification:........................................................................ .......................................................................................... CLINICAL OUTCOME:............................................................................................................................................................................ List all drugs including Over The Counter substances, natural remedies and additive-containing food taken at the time of the reaction: ............................................................................................................................................................................................................. ............................................................................................................................................................................................................. ............................................................................................................................................................................................................. SUSPICIOUS DRUGS: Drug’s generic name ± additives / Daily dose / Route of application Interval between dose and reaction: Previous therapy with this drug: Indication: / Duration of therapy: 1. .........mg/d; ............; .....d No Unknowm Yes -> Symptoms:........................... 2. .........mg/d; ............; .....d No Unknowm Yes -> Síntomas:............................. 3. ........mg/d; ............; ......d No Unknowm Yes -> Síntomas:............................. 4. ........mg/d; ............; ......d No Unknowm Yes -> Síntomas:............................. 5. ........mg/d; ............; ......d No Unknowm Yes -> Síntomas:............................. 6. ........mg/d; ............; ......d No Unknowm Yes -> Síntomas:............................. ............................................................................................................................................................................................................ CURRENT DRUGS: ....................................................................................................... MANAGEMENT FOLLOWING ACUTE DRUG REACTION: No therapy Antihistamines ....................................... Blockers ................................................ Stopping suspicious drugs No.# ............................................................................................... Antihistamines local systemic Corticosteroids local systemic Bronchodilatators local systemic Shock treatment Change to substitute/s: Epinephrine Plasma expanders Other: ..................................... Type/Name: ...................................................................................................................................... Tolerance: ........................................................................................................................................ Other / Specification:.......................................................................................................................... Dosis reduction (Drug................................).................................................................................................. Other / specify:............................................................................................................................................ 51
ENDA ANEXO. Drug hypersensitivity (cont.) PERSONAL HISTORY: 1) Have similiar symptoms been observed without the intake of the suspicious drugs? 2) MEDICAL HISTORY: Yes No Unknown Asthma Autoinmune (Sjögren, Lupus, etc) Urticaria pigmentosa / syst. mastocytosis Nasal polyposis Lymphoprolific (ALL, CLL, Hodgkin, etc.) Chronic urticaria Cystic fibrosis Intervertebral disk surgery HIV positivity Diabetes Liver:............................................................... Kidney: .......................................................... Other / Specification:....................................................................................................................................................................... 3) ALLERGIC DISEASES: ............................................................................................................................................................ (e.g. pollinosis, atopic dermatitis, food allergy, Hymenoptera venom allergy, latex alergy, etc.) 4) DRUG REACTIONS DURING PREVIOUS SURGERY: ............................................. Dentist Local anaesthesia Anestesia general 5) REACTIONS DURING PREVIOUS VACCINATIONS: ........................................ Polio Tetanus Rubella Measles Hepatitis B Diphteria Other................................ Unknown FAMILY HISTORY: Allergies / Drug allergies: ............................................................................................................................................................................................................. REMARKS: ............................................................................................................................................................................................................. ............................................................................................................................................................................................................. ............................................................................................................................................................................................................. DIAGNOSTIC PROCEDURES: RESULS ACUTE DIAGNOSTICS: (already performed) ................. DATE NORMAL ABNORMAL QUESTIONABLE Blood: Full blood count: Eosinophils............................ Value:..........rel.; ............abs. Other:................................... Value:..........rel.; ............abs. ECP (Eosinophil cationic protein) .......................... Value:........ C-reactive protein / Erythrocyte sedimentation rate Value:........ Flowcytometry (Specify: ....................................) ............................................. Tryptase ............................................................. Value:........ Liver parameters: GOT................................................................... Value:........ GPT................................................................... Value:........ γGT.................................................................... Value:........ alk. Phosphatase ............................................... Value:........ Kidney: Creatinine .......................................................... Value:........ Methylhistamine ................................................. Value:........ Others:............................................................... ............................................. Special: Mediators and metabolites (IL-4, IL-5, IL-10, IFNγ). Value:..................................... Immune complex analysis.................................... ............................................. Complement analysis........................................... ............................................. Skin biopsy .............................................................................................................................................. DIAGNOSTICS: NEGATIVE POSITIVE QUESTIONABLE Skin tests: Prick: ............................................................... Inmmediate-R. Late-R ............................................................................ Inmmediate-R. Late-R ............................................................................ Inmmediate-R. Late-R Intradermal: ....................................................... Inmmediate-R. Late-R ............................................................................. Inmmediate-R. Late-R Scratch-Patch: .................................................... Inmmediate-R. Late-R ............................................................................. Inmmediate-R. Late-R ............................................................................. Inmmediate-R. Late-R Other: ................................................................ Inmmediate-R. Late-R 52
Page 1 and 2: Alergol Inmunol Clin 2001;16: 48-53
Page 3: ENDA ANEXO. Drug hypersensitivity P

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