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 WardsPlan May go home

Home medicationsPrednisolone 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

DiagnosisFullfilment 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

Diagnosis2. 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

Diagnosis3. 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