Allergic Reaction Anaphylaxis Spectrum – © MedTx, LLC 2017 (Requires Free Log On)

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  • CC: year old with pertinent PMH/PSH of presents with
  • HPI:
    • hx of anaphalaxis
    • hx of requiring epi pen at home
    • By system:
      • hives
      • resp distress
      • n/v/d
    • precipitant known
    • History of similar symptom is past
      • never
    • Outcome of symptom in past
    • History unfortunately limited
      • secondary
        • to patient's condition,
        • to requirement of emergent diagnostics/interventions that take precedence over extensive history,
        • to patient's lack of understanding of their medical conditions,
        • to patient's lack of cooperative with interview,
        • to lack of medical records for this patient available in our system,
        • to lack of patient bringing medical information
  • REVIEW OF SYSTEMS:
    • Constitutional:
      • fevers,
      • rigors,
    • ENT:
      • rhinorrhea, otalgia, sore throat
      • as noted in HPI
    • Eye:
      • vision grossly intact
      • as noted in HPI
    • Cardiac:
      • chest pain,
      • LE swelling,
      • no unilateral LE swelling
      • as noted in HPI
    • Pulmonary:
      • shortness of breath,
      • cough,
      • as noted in HPI
    • GI:
      • abdominal pain,
      • nausea,
      • vomiting,
      • BRBPR, dark tarry stool,
      • diarrhea
      • as noted in HPI
    • GU:
      • no dysuria,
      • no discharge,
        • male specific:
          • no testicular pain,
        • female specific:
          • no abnormal vaginal bleeding,
      • as noted in HPI
    • Nuero:
      • no recent severe headache outside of normal headaches per patient,
      • no recent ALOC.
      • as noted in HPI
    • MSK:
      • no recent trauma
      • no focal weakness
      • as noted in HPI
    • Pysch:
      • normal speech
      • no SI,
      • no HI,
      • able to care for self
      • no AH
      • no VH
      • as noted in HPI
    • ID:
      • no recent antibiotics
    • Endo:
      • no polyuria/polydipsia
      • as noted in HPI
  • PMH/PSH/PSFH:
    • PMH/PSH:
      • medical/surgical history pertinent to chief complaint as noted in HPI
    • SH:
      • domiciled,
      • tob,
      • etoh use,
        • .
        • Pt advised not to drink/drive/use concurrent sedating meds/drugs and on cessation.
      • illicit drug use,
        • specifically
        • // Pt advised not to drink/drive/use concurrent meds/drugs and and on cessation
    • FH:
      • review and non-contributory to patient's presenting comwplaint.
  • Exam (Complaint specific/targeted aspects of exam):
    • peri-oral, lip, tongue swelling, visible swelling in back of oropharynx
    • wheezing, respiratory distress
    • hives
      • diffusely,
      • in inner thighs,
      • on chest,
    • vomiting
    • hypotension
  • ED COURSE and MDM:
  • Working Impression/Empiric Management:
  • Diagnostically:
    • Point of Care Testing:
      • Pregnancy Test
        • negative
    • Labs Reviewed and interpreted/correlated to clinical scenario to inform diagnosis and plan by me.
      • CBC:
        • No significant unexpected anemia, No significant leukocytosis, No thrombocytopenia.
        • Hg
          • anemia,
            • transfusion indicated given
              • symptomatic
              • < 7 Hg (6-8 range from restrictive transfusion strategy)
              • active significant bleeding
            • transfusion not indicated (considered)
            • peri-baseline,
            • significantly lower than baseline
            • unknown baseline,
            • suspected iron deficiency contributory, will advise/rx Ferrous sulfate 325mg daily w/ vit C.
        • wbc's
          • luekocytosis
            • suspect demarginalization given lack of infectious findings on hx/exam,
            • suggestive of infectious process,
            • concerning for malignancy, advised to for follow up
          • leukopenic
            • neutropenic
              • ((ANC < 500))
        • platelets:
          • thrombocytopenic
            • ((platelets < 150k))
            • transfusion not indicated
              • given suspected consumptive process
              • ((ITP, TTP, HIT))
          • transfusion indicated given
            • <10 k (regardless that pt is asymptomatic)
            • <20k and and planned CVP or pt febrile
            • <50k and planned LP or neurosurgical procedure
        • pancytopeniac
          • likely 2/2 chemo
          • likely 2/2 HIV
          • likely 2/2 hep C
          • unclear etiology, will initiate eval w/ completion of eval and monitoring/treatment to be continef as outpatientafter ED
      • BMP:
        • No significant pathologic electrolyte derangements.
        • AKI,
          • ((50% increase from baseline))
          • BUN/Cr >20 suggestive of prerenal process,
            • will administer IVF
            • and recheck
        • CKD,
          • grossly unchanged from prior
        • Hyperkalemia,
        • Anion gap
          • ((> 12))
        • acidotic suggested by low bicarb,
      • LFTs/lipase:
        • No laboratory evidence of hepato-biliary pathology.
        • Transaminitis without elevated bilirubin, suggestive of hepatic pathology
        • Elevated direct bilirubin suggestive of biliary pathology
        • Elevated indirect bilirubin suggestive of increased rbc breakdown
      • UA:
        • Not consistent with urinary tract infection.
        • Urine Cx sent with follow mechanism in place
        • Equivocal for infection
          • Empirically treated.
          • UCx sent with f/u mechanism in place
      • Cardiac Labs:
        • Troponin:
          • undetectable
          • <99th percentile
          • >99th percentile but under cut off for positive
          • positive
        • Delta troponin
          • undetectable
          • <99th percentile
          • >99th percentile but under cut off for positive
          • positive
        • BNP:
          • ::- please note that greater than 500 suggests CHF, under suggests not CHF -::
          • not suggestive of CHF exacerbation
          • suggestive of CHF exacerbation
          • equivocal
      • HIV:
        • negative,
        • positive,
          • I discussed this finding with patient in sensitive private manner, educated on treatment options, offered resources, answered all questions, advised to have partner evaluated and advised to refrain from any of the common modes of transmission.
        • Prior to test sent, pt was informed that we advise for testing for HIV. Pt did not opt out.
      • Influenza
        • negative
      • CK:
        • significantly elevated, requires trending ::- usually for >500-1000k -::
        • mildly elevated, not anticipated to rise given negated precipitant
        • negative
      • Ingestion labs:
        • acetaminophen
          • non-detectable,
        • ASA:
          • non-detectable,
        • etoh
          • non-detectable
          • positive
      • Urine toxicological screen:
        • negative
        • postive for
      • Markers of inflammation
        • CRP ::- suggestive of more acute inflammation -::
          • wnl
          • elevated
        • ESR ::- suggestive of more chronic inflammation -::
          • wnl
          • elevated
  • Radiographically:
    • Radiographs ordered, pending at this time.
    • Radiographs reviewed, interpreted by me.
    • Radiographs reviewed by me, agree with radiology interpretation.
    • Radiology interpretation reviewed.
    • CXR:
      • Normal study: no tracheal deviation, non-widened mediastenum, normal cardiac boarder, no pleural effusion, no air under diaphragm, no focal consolidation, no PTX, no gross bony abnormalities.
      • Pulmonary edema,
      • Cardiomegaly,
      • lobar opacity,
      • diffuse radio-opacities
      • pneumothorax
        • on right
        • on left
        • mediastenium midline
        • (This is an ED prelim radiographic interpretation in order to increase chance of finding obvious emergent pathology which can be intervened upon and to minimize delay in care secondary to delay of radiology to be able to provide formal reads. Given these studies require board certified radiologists to review and formal reads are beyond the scope of Emergency Medicine, institutional protocol in place which will alert current care team/patient for over-reads/changes/critical reads).
  • MDM (with A/P):
    • Organ systems involved:
      • respiratory
      • skin
      • GI
      • cardiovascular (hypotension)
    • Suspect
      • allergic reaction
        • given only one organ system involved.
        • tx:
          • -dexamethasome
            • 0.6mg/kg
            • (max 16mg IV )
          • -benadryl
            • 1mg/kg
            • (max 50mg IV )
          • -famotidine
            • 0.5mg/kg IV or PO
            • (max 20mg)
          • -considered epi though given allergic rxn w/o e/o anaphalaxis, not indicated at this time.
        • DDx (considered and not consistent with):
          • Considered anaphalaxis however given only one organ system involved, not consistent with anaphalaxis and suspect allergic reaction.
      • anaphalaxis given >=2 organ systems involved.
        • tx:
          • -IVF bolus
          • -dexamethasome
            • 0.6mg/kg
            • (max 16mg IV )
          • -benadryl
            • 1mg/kg
            • (max 50mg IV )
          • -famotidine
            • 0.5mg/kg IV or PO
            • (max 20mg)
          • -epi SC given e/o anaphalaxis
            • 0.15mg SC for <15kg
            • 0.3mg SC for >15kg
            • redosed as indicated based upon re-eval and responsive
        • MAP goal 65
          • Does not require pressors at this time.
          • Vasopressors required for MAP goal,
            • norepinephrine required, initiated.
              • ((range 2-20mcg/min))
            • epinephrine required, initiated.
              • ((range 1 – 20 mcg/min)))
            • vasopressor required, initiated
              • ((usual dose 0.4u / min))
          • Access:
            • Pressors run peripherally as is considered safe for a finite duration. To be switched to central access if pressor requirement persists.
            • Central access obtained given anticipated prolonged dependence on pressors.
        • Intubation
          • not indicated at this time given pt is maintaining airway
          • given signs of impending respiratory/airway compromise, anticipated clinical course likely leading to subsequent attempt riskier difficult intubation.
        • DDx (considered and not consistent with):
          • Considered allergic reaction however given >=2 one organ systems involved, pt meets criteria for anaphalaxis and benefits of treatment outweigh risks of withholding treatment.
  • Dipso:
    • home given pt observed for > 4-6 hours from onset of sx and showed continued improvement, no recurrence of symptoms, therefore likely observed past duration of anticipated biphasic reaction.
      • rx for epipen
      • advised to take benadryl q 4 hrs for 2 days (advised be watched by family/not to drive/drink/at fall risk/use other sedating medications)
      • advised to avoid any suspsected precipitants
      • advised for prompt f/u with PMD for further evaluation for precipitant (would likely benefit from eval by allergist)
      • implored return precautions – specifically recurrence of any of the above the symptoms, resp sx, GI sx, hives, symptoms suggestive of early shock
    • admitted for continued observation , evaluation, treatment
  • Supplemental Documentation:
    • Observation time:
      • onset of observation time
      • end of observation time
    • DIAGNOSIS:
      • ICD-10 code:
    • COUNSELING:
      • Patient/family educated to the extent possible in terminology matched to their understanding on diagnostics, assessment, and treatment plan along with the risks inherent to the diagnostics and therapeutics and plan. Patient/family amendable and in agreement with above plan. All questions and concerns addressed and answered.
      • Attempted shared decision making in discussion with patient/family in all circumstances where feasible and possible.
      • COUNSELING: Attempted to explain and obtain patient's approval for plan however unable to do so secondary to patient's condition and the requirement of emergent evaluation and interventions.
      • SUPERVISION: Discussed and obtained approval/confirmation of evaluation (history, exam, diagnostics) and plan (assessment, interventions, disposition) with ED attending physician
      • Of note, follow up over-read mechanism in place for over-reads and follow up of pending diagnostics

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