1. Bianca Cruz

2.  X.R.  8 year old male  Roman Catholic  Makati  Informant: Mother (80% reliability)

3. Difficulty of Breathing

4.  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

5. 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

6. 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

7.  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

8.  No previous hospitalizations  No previous surgeries  No allergies to food or medicines

9.  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

10.  Breastfed until less than 6 months  Weaned at 6 months  No food preferences

11.  BCG  DPT  HIB  Hepa B  Measles  MMR (Incomplete)

12.  Hypertension

15.  Anaphylaxis

16.  Asthma  Pneumonia  Viral Exanthem

17.  Consider pneumonia, right

18.  Bacterial Infection

19.  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

20.  Watch out for  Difficulty of breathing  Recurrence of urticarial rashes  Tachypnea

21. 9 March 2012; Day 4 of Illness; Day 1 of Hospital stay

23. 10 March 2012; Day 5 of Illness; Day 2 of Hospital stay

25. 11 March 2012; Day 6of Illness; Day 3 of Hospital stay

28.  Acute multi-organ system hypersensitivity reaction  Needs previous exposure to allergen to develop hypersensitivity reaction  Initial exposure may be through breast milk

29.  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)

30.  Food  Latex gloves  Medications

31.  Cutaneous  Urticaria, angioedema, flushing  Pruritus, sensation of warmth, periorbital edema  Respiratory  Bronchospasm, laryngeal edema  Throat tightness, dry cough, dyspnea, cough, wheezing, nasal congestion

32.  Cardiovascular  Hypotension, dysrhythmias, myocardial ischemia  Loss of consciousness  Gastrointestinal  Nausea, abdominal pain, vomiting and diarrhea  Injected allergens – most rapid reaction

33. 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

34. 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

35. 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

36.  Briefly elevated plasma histamine  Plasma Beta-tryptase – remain elevated for several weeks

37.  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

38.  Administer Histamine-1 receptor antagonist  Ex. diphenhydramine  Give corticosteroids  Helps prevent late phase of the allergic response  Methylprednisone  Prednisone  Volume expanders  NSS, D5LR

39.  Biphasic anaphylaxis  Recurrence of anaphylactic symptoms after resolution  New onset of symptoms – more severe  Late treatment

40.  Allergen avoidance  Epinephrine autoinjection  Liquid cetirizine or diphenhydramine  Written emergency plan  Usage of oral medications vs. IV  Immunotherapy