Select your language:

D. Questionnaires/letters

D.1. AN EXAMPLE OF A SUITABLE LETTER FOR THE PATIENT TO TAKE TO THE ALLGERGY CONSULTATION

 

Dear colleague,

(Insert patient's name and details) had a hypersensitivity reaction after the administration of a contrast agent on (insert date)

Examination type (e.g. CT, MRI, IV.....):

Type of contrast agent:

    • iodine-based
    • gadolinium-based
    • ultrasound

Name of the contrast agent:

Dose administered:                                                                   ml

Route of administration (e.g. IV, IA, intra-articular, oral, local......):

Time between the injection and the start of the clinical symptoms:

Type of symptoms (describe):

 

Grade of the reaction according to the Ring and Messmer classification:

    • Grade 1
    • Grade 2
    • Grade 3
    • Grade 4

 

Grade    Dermal     Abdominal     Respiratory     Cardiovascular    
1

Pruritus

Flushing

Urticaria

Angioedema

     
2

Pruritus

Flushing

Urticaria

Angioedema 

Nausea

Cramping

 

 

Rhinorrhea

Hoarseness

Dyspnea

 

Tachycardia (> 20 bpm)

Blood pressure change (> 20 mm Hg systolic)

Arrhythmia

  

3

Pruritus

Flushing

Urticaria

Angioedema

Vomiting

Defecation

Diarrhea

 

Laryngeal edema

Bronchospasm

Cyanosis

 

Shock

 

 

 

4

Pruritus

Flushing

Urticaria

Angioedema

Vomiting

Defecation

Diarrhea

 

Respiratory arrest 

 

 

 

Carciac arrest

 

 

 

 

 Treatment given during the reaction:

    • (please specify)

 

Outcome (e.g. follow up, ICU, return home ......):

Histamine and/or Tryptase blood tests:

Blood test performed at the time of the reaction                       Yes/No

2 hours later                                                                         Yes/No

Results:  Histamine: 

             Tryptase: 

 

Previous history of contrast agent reaction                                 Yes/No

If yes, please specify type of contrast agent and symptoms

 

 

Thank you for seeing the patient and performing skin testing to categorize the reaction as either allergic or non-allergic hypersensitivity, and to look for cross-reactivity so that a safer contrast agent can be recommended for future injections.

 

Your sincerely,

Dr (Name and details)

 

  

D.2. QUESTIONNAIRE FOR IODINE-BASED CONTRAST MEDIA ADMINISTRATION TO BE COMPLETED BY THE REFERRING CLINICIAN

  

Questionnaire for iodine-based contrast media administration to be completed by the referring clinician
   Yes No
1. History of moderate or severe reaction to an iodine-based contrast medium         
2. History of atopy requiring treatment    
3. History of unstable asthma    
4. Hyperthyroidism    
5. Heart failure    
6. Diabetes mellitus    
7. History of renal disease    
8. Previous renal surgery    
9. History of proteinuria    
10. Hypertension    
11. Gout    
12.

Most recent measurement of serum creatinine

• Value.............................................
• Date ..............................................

 

 

13.

Is the patient currently taking any of the following drugs

 
  • Metformin

 

 
 
  • Interleukin 2

 

 
 
  • NSAIDs

 

 
 
  • Aminoglycosides

 

 
 
  • ß-blockers

 

 

 

Completed by ______________________________________ Date ________________________

 

 

 

D.3. QUESTIONNAIRE FOR GADOLINIUM-BASED CONTRAST AGENT ADMINISTRATION TO BE COMPLETED BY THE REFERRING CLINICIAN

 

Questionnaire for gadolinium-based contrast agent administration to be completed by the referring clinician

  Yes No
1. History of moderate or severe reaction to a gadolinium-based contrast medium            
2. History of atopy requiring treatment    
3. History of unstable asthma     
4. Has the patient end-stage renal failure (eGFR < 30 ml/min/1.73m2) or is the patient on dialysis    
5. Has the patient reduced renal function* (eGFR between 30 and 60 ml/min/1.73 m2)          

* Only if high-risk agents are used

 

Completed by ______________________________________ Date ________________________

 

 

 

 

 

 

Home D. Questionnaires