bianca cruz. x.r. 8 year old male roman catholic makati informant: mother (80% reliability)
TRANSCRIPT
Case PresentationBianca Cruz
General Information
X.R. 8 year old male Roman Catholic Makati Informant: Mother (80% reliability)
Chief Complaint
Difficulty of Breathing
History of Present Illness
Colds Productive cough with whitish phlegm No fever, no DOB, no abdominal pain,
no vomiting No consult done, no meds taken
• Colds• Productive cough with yellowish
phlegm • Undocumented fever• No DOB, no abdominal pain, no
vomiting• No consult done, no meds taken
3 days PTA
2 days PTA
History of Present Illness
• Colds• Productive cough with yellowish
phlegm • Undocumented fever• Difficulty of breathing• Chest pain during inspiration and
coughing• Rx: Paracetamol, 5ml (250mg/5ml) • Helped lyse the fever
• No consult done, no meds taken
1 day PTA
History of Present Illness
• Colds• Productive cough with yellowish
phlegm • Undocumented fever• Difficulty of breathing• Chest pain during inspiration and
coughing• No consult done, no meds taken• Appearance of non-pruritic
erythematous wheals on arms, legs, trunk and torso
2 hours PTA
CONSULT
Review of Systems General: (-) weight loss, (-) weakness HEENT: (-) dizziness, (-) BOV, (-) rhinorrhea, (-)
epistaxis, (-) dysphagia Respiratory: (-) hemoptysis Cardiovascular: (-) palpitations, (-) cyanosis, (-)
easy fatigability, Gastrointestinal: (-) abdominal pain, (-) changes
in bowel movements Genitourinary: (-) dysuria, (-) frequency, (-)
hematuria Musculoskeletal: (-) muscle pain, (-) dysarthria, (-)
weakness of extremities Dermatologic: (-) erosions, (-) excoriations
Past Medical History
No previous hospitalizations No previous surgeries No allergies to food or medicines
Birth History
Born full term via NSD Attended by an OB PNCU > 10 4 UTZ Normal CBC and urinalysis Non-reactive HbsAg 25 year old mother, G1P1 (1-0-0-1) Unrecalled birthweight and APGAR score
Nutritional History Breastfed until less than 6 months Weaned at 6 months No food preferences
Immunization
BCG DPT HIB Hepa B Measles MMR (Incomplete)
Family History
Hypertension
Physical ExaminationVital Signs HR= 112; RR= 20; T= 36.9 C; BP= 110/80
Anthropometrics Height = 130 cm; Weight = 31.1 kg; BMI: 18.5
General Well-groomed, not in cardio-respiratory distress, alert and coherent, not in pain
HEENT Anicteric sclera, pink palpebral conjunctivae, (-) CLAD, white, exudative lesions on Right tonsil, flat neck veins
Cardiovascular Adynamic precordium, NRRR, (-) murmurs, PMI at 5th LICS MCL
Physical ExaminationRespiratory Equal chest expansion, no retractions, tight air entry, (+)
bilateral wheezing, (-) crackles
Abdomen Flat abdomen, NABS, tympanic on all quadrants, soft, non-tender, non-palpable liver edge, 5cm liver span, Traube’s space not obliterated
Skin Erythematous patches on arms, legs back and abdomen, good skin turgor, CRT <2 secs
Extremities No edema, no cyanosis, full and equal pulses
Primary Impression
Anaphylaxis
Differentials
Asthma Pneumonia Viral Exanthem
CXR
Consider pneumonia, right
CBC
Bacterial Infection
Parameter ValueHemoglobin 135Hematocrit 0.40RBC 4.84WBC 23.70 (high)MCH 28MCHC 0.34MCV 82RDW 13.8Platelet 327
Parameter ValueMonocyte 0.06Eosinophils 0.00Neutrophil 0.79 (high)Lymphocytes 0.26 (low)
Plan: Therapeutics
D5NM 1L x 79ml/hr (+ 10%) Hydrocortisone 100mg/IV every 6 hours Diphenhydramine 32 mg/IV every 6 hours Salbutamol nebules, 1 nebule every 4
hours Paracetamol 250mg/ml, give 6.5ml every 4
hours for temperature >/= 37.8 Cefuroxime 750mg/IV every 8 hours
Plan
Watch out for Difficulty of breathing Recurrence of urticarial rashes Tachypnea
Course in the WardsSubjective Patient seen asleep
Afebrile since admission Still with coughing episodes No complaints of difficulty of breathing
Objective T = 36.2; RR = 28; HR = 92; BP = 100/60 No periorbital edema, anicteric sclerae, pink palpebral conjunctivae (-) CLAD, (-) TPC Adynamic precordium, no murmurs, NRRR, PMI at 5th LICS MCL Equal chest expansion, no retractions, (+) rales, no wheezing Flat abdomen, soft, non-tender Full and equal pulses , CRT <2s No rashes
9 March 2012; Day 4 of Illness; Day 1 of Hospital stay
Course in the WardsAssessment Anaphylaxis
PneumoniaPlan Decrease nebulization to q 6 hours
WOF: difficulty of breathing, cyanosis, tachypnea, recurrence of urticarial rashes
9 March 2012; Day 4 of Illness; Day 1 of Hospital stay
Course in the WardsSubjective Patient was awake, alert
Afebrile since admission Still with coughing episodes No complaints of difficulty of breathing
Objective T = 36.2; RR = 28; HR = 92; BP = 100/60 No peiorbital edema, anicteric sclerae, pink palpebral conjunctivae (-) CLAD, (-) TPC Adynamic precordium, no murmurs, NRRR, PMI at 5th LICS MCL Equal chest expansion, no retractions, (+) rales, no wheezing Flat abdomen, soft, non-tender Full and equal pulses , CRT <2s No rashes
Assessment Anaphylaxis Pneumonia
10 March 2012; Day 5 of Illness; Day 2 of Hospital stay
Course in the WardsPlan Decrease nebulization to q 6 hours
WOF: difficulty of breathing, cyanosis Discontinue Diphenhydramine and Hydrocortisone IV Maintain nebulizations Shift Hydrocortisone to Prednisolone (20mg/5ml). 4ml twice a day before meals Shift diphenhydramine IV to diphenhydramine oral
10 March 2012; Day 5 of Illness; Day 2 of Hospital stay
Course in the WardsSubjective Patient seen asleep
Afebrile since admission Still with coughing episodes No complaints of difficulty of breathing
Objective T = 36.2; RR = 28; HR = 92; BP = 100/60 No peiorbital edema, anicteric sclerae, pink palpebral conjunctivae (-) CLAD, (-) TPC Adynamic precordium, no murmurs, NRRR, PMI at 5th LICS MCL Equal chest expansion, no retractions, (+) rales, no wheezing Flat abdomen, soft, non-tender Full and equal pulses , CRT <2s No rashes
Assessment Anaphylaxis Pneumonia
11 March 2012; Day 6of Illness; Day 3 of Hospital stay
Course in the Wards
Plan May go homeHome medications
Prednisolone 20mg/5ml; give 2 ml 2x a day for 3 more days Diphenhydramine 125mh/5ml; give 3.5ml 4x a day for 3 more
daysCefuroxime 250mg/5ml; give 7ml 2x a day
Follow-up after 1 week
11 March 2012; Day 6 of Illness; Day 3 of Hospital stay
ANAPHYLAXIS
What is Anaphylaxis
Acute multi-organ system hypersensitivity reaction
Needs previous exposure to allergen to develop hypersensitivity reaction Initial exposure may be through breast
milk
Hypersensitivity Reaction
Exposure to allergen sensitization of B-lymphocytes
Re-exposure to allergen activation of allergen specific IgE molecules activation of mast cells and basophils release of cell mediators (histamine, tryptase, prostaglandins, cytokines)
Common Allergens
Food Latex gloves Medications
Clinical Presentation
Cutaneous Urticaria, angioedema, flushing Pruritus, sensation of warmth, periorbital
edema Respiratory
Bronchospasm, laryngeal edema Throat tightness, dry cough, dyspnea,
cough, wheezing, nasal congestion
Clinical Presentation
Cardiovascular Hypotension, dysrhythmias, myocardial
ischemia Loss of consciousness
Gastrointestinal Nausea, abdominal pain, vomiting and
diarrhea Injected allergens – most rapid
reaction
Diagnosis
Fullfilment of any one of the 3 criteria
1. Acute onset of illness with involvement of the skin and/or mucosal tissue AND at least 1 of the ff: Respiratory compromise
Dyspnea, wheezing, hypoxemia Reduced BP or associated symptoms of
end-organ dysfunction Hypotonia, syncope, incontinence
Diagnosis
2. Two or more of the ff. that occur rapidly after exposure to a like LIKELY allergen for that patient Skin/ mucosal involvement
Generalized hives, swollen lips/ tongue, uvula Respiratory compromise
Dyspnea, wheezing, stridor, hypoxemia Reduced BP
Hypotonia, syncope Persistent GI symptoms
Vomiting, crampy abdominal pain
Diagnosis
3. Reduced BP following exposure to a KNOWN allergen for the patient Infants and children
Low systolic BP More than 30% drop in systolic BP
Adults Systolic BP < 90mmHg > 30% drop from baseline
Laboratory Findings
Briefly elevated plasma histamine Plasma Beta-tryptase – remain
elevated for several weeks
Treatment
Ensure adequate airway, circulation and perfusion
Administer Epinephrine IV: No IV: given IM
0.01 mg/kg, max 0.3 – 0.5 mg Persistence of symptoms: Can be repeated
2-3 times between 5-15 min intervals
Give nebulized albuterol
Treatment
Administer Histamine-1 receptor antagonist Ex. diphenhydramine
Give corticosteroids Helps prevent late phase of the allergic
response Methylprednisone Prednisone
Volume expanders NSS, D5LR
Complications
Biphasic anaphylaxis Recurrence of anaphylactic symptoms
after resolution New onset of symptoms – more severe Late treatment
Prevention
Allergen avoidance Epinephrine autoinjection Liquid cetirizine or diphenhydramine Written emergency plan Usage of oral medications vs. IV Immunotherapy