Drug hypersensitivity: questionnaire Special article
Drug hypersensitivity: questionnaire Special article
Drug hypersensitivity: questionnaire Special article
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ANEXO. <strong>Drug</strong> <strong>hypersensitivity</strong> (cont.)<br />
<strong>Drug</strong> <strong>hypersensitivity</strong>: <strong>questionnaire</strong><br />
Blood analysis: Total IgE Value:.........................<br />
Specific IgE for drugs: CAP RAST Value:.........................<br />
............................................................................ Value:.........................<br />
............................................................................ Value:.........................<br />
............................................................................ Value:.........................<br />
Specific IgG / Coombs Test dir:........................................................................................................................<br />
Coombs test indir...........................................................................................................................................<br />
Other............................................................................................................................................................<br />
Cellular tests: Lymphocyte transformation test (TTL):...................................... YES:.................<br />
.............................................................................................. YES:.................<br />
.............................................................................................. YES:.................<br />
Basophil activation test (Specify:: ..........................................) .....................<br />
CAST assay........................................................................... .....................<br />
Other:.................................................................................. .....................<br />
CONCLUDING INTERPRETATION:<br />
Type I reaction (IgE mediated) a: A.........................................................................................<br />
Type II reaction (antibody mediated) a: B.........................................................................................<br />
Type III reaction (inmune complete mediated) a: C.........................................................................................<br />
Type IV reaction (cell-mediated, late-type reaction) a: D.........................................................................................<br />
Cytotoxic reaction, cell-mediated a: E.........................................................................................<br />
Pseudoallergic reaction a: F..........................................................................................<br />
Pharmacological reaction a: G.........................................................................................<br />
Psychophysiological reaction a: H.........................................................................................<br />
Other:............................................................... a: I..........................................................................................<br />
Test de provocación: Local anesthetics:...............................................<br />
NSAID:..............................................................<br />
..............................................................................<br />
..............................................................................<br />
Aspirin:..............................................................<br />
Paracetamol:.......................................................<br />
Nimesulid:..........................................................<br />
β-lactam:............................................................<br />
.............................................................................<br />
Other:.................................................................<br />
PROBABILITY SCALE CONCERNING THE CAUSAL RELATIONSHIP BETWEEN DRUG & REACTION: (Please mark the drug’s letter on the scale)<br />
Certain Probable Possible Doubtful Unrelated/Not assessible<br />
Please specify:........................................................................................................................................................................................<br />
DECLARATION TO REGULATORY AGENCY: No Yes To whom?: ................................................................................Date: .........<br />
REMARKS:............................................................................................................................................................................................<br />
.............................................................................................................................................................................................................<br />
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