GRAND ROUNDS CASE PRESENTATION

GENERAL OBJECTIVE
 To present a case of S.O.Y., a 16-year-old male who came in for syncope.

SPECIFIC OBJECTIVE
 To present the history and clinical manifestations of the patient
 To discuss the etiology and pathophysiology of Anaphylaxis
 To discuss the diagnosis, treatment, complications and prognosis of Anaphylaxis

CASE PROTOCOL: This is a case of SOY, a 16-year-old male, Filipino, born on December 26, 2006,
Roman Catholic, from Basey, Western Samar, was admitted for the first time last July 27, 2023
due to syncope and urticaria.

History of Present Illness

Sixteen hours prior to admission, patient noted difficulty of breathing associated with
chest pain described as heaviness, nonradiating while lying on bed, body weakness and
syncope, two episodes, described as complete loss of consciousness of approximately less than
one minute preceded by blurring and tunnelling of vision with spontaneous recovery. No noted
dyspnea, abdominal pain, vomiting, incontinence, oral trauma, confusion nor myalgias. Patient
was rushed to a public district hospital. An elevated blood pressure was noted at 160/100mmHg
thus was given Carvedilol 25 mg/tab, one tab sat dose and pruritic skin rashes located at the
face and chest given Diphenhydramine 50 mg IV, stat dose. Laboratories were done included
complete blood count which showed hemoglobin of 163 g/L, hematrocrit of 0.50 l/l,
neutrophilia at 81% and decreased lymphocytes of 15% with platelet count of 329 l/I, blood
chemistry as follows blood uric acid at 530 umol/L, creatinine 90.4 umol/L, BUN 3.60 mmol/L,
SGPT 34.4 U/L and SGOT 22.7 U/L. The serum electrolytes requested showed results of
decreased potassium of 3.3 mmol/L, sodium 137 mmol/L and ionized calcium of 109 mmol/L.
Urinalysis had normal results. Diagnostics such as 12 lead ECG and Chest xray APL were normal.
Twelve hours prior to admission, patient was referred to a private hospital and was
admitted for persistent hypertension and pruritic skin rashes associated with abdominal pain,
blurring of vision and difficulty of breathing. Started on Hydrocortisone 100mg IVTT every 12
hours, Diphenhydramine 25mg IVTT every 12 hours, Omeprazole 40mg IVTT every 24 hours, and
Salbutamol nebulization, one nebule every 6 hours and Carvedilol 25 mg/tab, one tablet once
daily was continued.
Two hours prior to admission, while admitted at the private hospital, patient
experienced chest tightness associated with difficulty of breathing and body weakness followed
by a syncopal attack while at the bathroom, described as complete loss of consciousness of
approximately less than one minute also preceded by blurring and tunnelling of vision with
spontaneous recovery. There was slurring of speech noted. Still no incontinence, oral trauma,
confusion nor myalgias. The patient had elevated blood pressure at 170/70mmHg and fever
with Tmax of 38.3C, tachycardic at 99bpm and tachypneic at 23cpm. Upon physical examination,
there was persistence of facial and chest erythematous rashes and decreased muscle strength
of both upper and lower extremities. Given Clonidine 75mg/ tab, one tablet sublingual as stat
dose and Paracetamol 300mg IVTT. Patient was referred to our institution for close monitoring
at the intensive care unit.

REVIEW OF SYSTEMS

CVS (+) palpitations

CUTANEOUS (+) flushed skin
HEENT (+) headache, (+) dizziness, (+) blurring of vision, no hoarseness, no loss of voice
RESPIRATORY (+) cough, nonproductive, no difficulty of breathing

MATERNAL AND BIRTH HISTORY

He was born full term, with good cry and activity to a then 27 year old, G3P3 (3003)
nonalcoholic, nonhypertensive mother, via Normal Spontaneous Delivery at home assisted by
traditional birth attendant. The mother had no exposure to teratogenic substances but had
Urinary Tract Infection on the second trimester of pregnancy but no medications were given.

GROWTH AND DEVELOPMENT

GROSS MOTOR
8 months- sat without support
10 months- stood alone
15 months- walked alone without support
2 years- ran well
3 years- climbed well
4 years- caught a bounced ball

LANGUAGE
12 months- followed 1 step command
2 years- pointed body parts, 3 words sentences
3 years- said first name
4 years- said first and last name
FINE MOTOR
2 years- imitated vertical line
3 years- turned book page
4 years- copied some letter

PERSONAL AND SOCIAL

10 months- bid bye-bye
12 months- kissed on request
3 years- dressed self
 4 years- played with other children

24-HOUR DIET RECALL

Breakfast- 2 slices canned luncheon meat (Maling), ½ cup rice
Lunch- ½ cup pork adobo, ½ cup rice
Snack- biscuit
Dinner- ¼ cup ground pork, ½ cup rice
Breakfast- ½ slice fried bangus, ½ cup rice

IMMUNIZATION

BCG and Hepatitis B vaccine given at birth; Pentavalent vaccine (DPT-HepaB-HIB), OPV and
Pneumococcal Conjugate Vaccine (PCV) given starting at 1.5 months for 3 doses, one month
apart; Inactivated Polio Vaccine (IPV) given at 3.5 months and Measles, Mumps and Rubella
(MMR) vaccine given at 1 year old. Covid-19 vaccine (Pfizer) given for 2 doses. No booster doses
given. No annual influenza vaccine received.

PAST MEDICAL HISTORY

Patient is a known allergies to foods since childhood with no maintenance medications, last
attack was last 2009 and was given short acting Beta agonist with relief of symptoms. There was
a previous admission for 3 days at a local government hospital last 2022 for difficulty of
breathing and transient loss of consiousness in which he was discharged improved. Patient has
known allergy to foods like chicken, eggs and canned goods. Additionally, was diagnosed with
Cold Urticaria by a private dermatologist (about a week prior to admission). Given Fexofenadine
Hydrochloride 120mg/tab, once daily, Lobetasol propionate 0.05% cream to affected areas and
Vitamin C Supplementation.

FAMILY MEDICAL HISTORY

Patient is the third among siblings. His 43-year-old hypertensive mother, 49-year-old
hypertensive father, and five siblings were all apparently well. On the maternal side, a history of
recurrent Anaphylaxis was noted on the Aunt with emergency Epinephrine pen use and
Bronchial Asthma. A history of Diabetes Mellitus is noted on the paternal side of the family.
Both parents have a family history of Hypertension. No other heredofamilial diseases noted. No
history of sudden cardiac death nor malignancy in the family.

FAMILY GENOGRAM
SOCIOECONOMIC AND ENVIRONMENTAL HISTORY

Both parents manage a family-owned business. The patient is the third of six siblings. He lives in
a two-storey fully concrete house with good ventilation and electricity source, which is shared
with nine household members. There are no sick family members noted. The source of drinking
water is mineralized bought from a refilling station. The garbage is collected three times weekly.
The family owns cats as pets. No noted exposure to cigarette smoking.

HEADDS

HOME
Patient lives with parents and five other siblings. He has his own room in a concrete 2-storey
family-owned house. He has a good relationship and open communication with all family
members.

EDUCATION
He is a Grade 11 honor student and athlete in Liceo del Verbo Divino, Tacloban City. Patient goes
to the same school with two other siblings. He denies experiencing bullying in school. Patient
felt safe in school.

EATING HABITS
Patient is not a picky eater with good appetite, however, he has reported allergies to foods such
as chicken, eggs, some fish types and canned goods. He is not concerned about his weight nor
body changes.

ACTIVITIES
Patient plays volleyball and enjoys playing mobile games. He spends an ample time in different
social media platforms.

DRUGS/ ALCOHOL
Patient denies illicit drug use. He is a nonsmoker and non-alcoholic beverage drinker.

SEXUALITY
He is attracted to both sexes, male and female, but denies engaging in sexual activities.

SUICIDALITY
Patient had suicidal ideation during the pandemic. He felt depressed but denies hurting himself.
He negates any major family problems.

SAFETY
He feels safe at home and in the neighborhood. Patient denies any experience of abuse. He has
not encountered any major accidents.

PHYSICAL EXAMINATION:
General Survey: The patient was drowsy with speech difficulty, coherent, oriented to time, place
and person, well-nourished, well-developed, in cardiorespiratory distress

Vital Signs
BP: 135/52 mmHg HR: 90bpm RR: 27cpm Temp: 37.9C CRT <2 seconds
O2 sat: 100% on O2 support at 5LPM via nasal cannula

Anthropometric Data and Z-score:

Weight: 65 kg
Height: 157 cm
BMI: 26.4 (93th percentile for boys aged 16 years old or overweight)

HEENT:
Symmetrical facial features with urticarial rashes (blanchable, eythematous, raised rashes, some
linear and annular) sparing periorbital and perioral areas; no palpable head mass, hair normal
texture and equally distributed; anicteric sclerae, pink palpebral conjunctiva, eyes not sunken;
symmetrical, midline nose with nasal discharge, angioedema of lips and tongue; tonsils not
assessed; no cervical lymphadenopathy

CHEST AND LUNGS:

Urticarial rashes on chest and back; Symmetrical chest expansion, clear breath sounds, no
wheezing, no crackles, no retractions

CARDIOVASCULAR SYSTEM:
Adynamic precordium, tachycardic, regular rhythm, distinct S1 and S2, no murmur

ABDOMEN:
Flabby, with urticarial rashes noted, normoactive bowel sounds, soft, nontender, tympanitic all
over

EXTREMITIES:
Grossly normal extremities with urticarial rashes, no edema, no clubbing, full and equal pulses

SEXUAL DEVELOPMENT (TANNER’S SEXUAL MATURITY RATING):

Stage IV- increased size of penis, nonedematous, with growth in breadth and development of
glans; testes and scrotum larger, scrotal skin darker

NEUROLOGIC EXAMINATION
GLASCOW COMA SCALE 15

MENTAL STATUS
drowsy, coherent, oriented to time, place and person

CRANIAL NERVES

CN I- no anosmia
CN II, III- pupils equal, reactive to light and accomodation with good peripheral vision
CN III, IV, VI- no nystagmus, intact EOM
CN V, VII- (+) corneal reflex
CN VII-no facial asymmetry
CN VIII-no hearing loss; responsive to verbal stimuli
CN IX, X- intact gag reflex
CN XI-able to turn head and shrug shoulder against resistance
CN XII-tongue at midline, no fasciculations

Motor- No atrophy; decreased muscle strength at 3/5- active movement against gravity in all
extremities and weak functional grip
Sensory- Intact sensory function of both lower and upper extremities to light touch and
pressure, withdraws from painful stimulus equally
Cerebellar-no dysdiadokinesia, well-coordinated movements
Meningeal- no nuchal rigidity, negative Kernig’s sign, negative Brudzinki’s sign
Pathologic-negative Babinski, negative Chaddok

ADMITTING IMPRESSION:
HYPERTENSIVE EMERGENCY; to consider STROKE IN THE YOUNG;
HYPERTENSITIVITY DISORDER probably secondary to FOOD INTAKE

COURSE IN THE WARDS:

HOSPITAL DAY 1 (7/27/23)

At the emergency room, patient was drowsy, follows command, oriented to time, place
and person. Patient was in cardiorespiratory distress, tachypneic at 27 cpm and tachycardic at
90 bpm with elevated blood pressure at 135/52 mmHg hence was given O2 support via face
mask at 5LPM with 100% O2 saturation. The Glascow Coma Scale score was 15 (E4V5M6).
Noted to have slurring of speech but no facial asymmetry and tongue was midline. The skin was
flushed with nonpruritic urticarial lesions on the face, chest and back and swelling of the lips,
tongue and eyelids with sunken eyeballs. The lungs were clear on auscultation. Abdomen was
flat, with erythematous, raised wheals, normoactive bowel sounds with generalized tenderness.
There was full range of motion in all extremities against gravity but not against resistance and
weak functional grip. No loss of sensation. No involuntary movements were noted. Patient was
placed on NPO temporarily, hydrated with PNSS at full maintenance rate. Medications started
were Diphenhydramine 50mg IV stat dose, Ranitidine IV 2mkday every 8 hours and Paracetamol
300mg IV stat dose then as needed for fever with temperature equal to or more than 38C.
Laboratories requested were as follows Complete Blood Count with Platelet count, Serum
Electrolytes, Blood Uric Acid, Blood Urea Nitrogen, Creatinine, SGPT, 15 Lead Electrocardiogram,
Chest Xray Posterior-Anterior-Lateral view, Whole Abdominal Ultrasound and Covid-19 Antigen
test. Patient was referred to a Pediatric Intensivist, Pediatric Cardiologist and Pediatric
Neurologist for further evaluation and management. Cardiologist ordered for blood pressure in
all extremities as follows taken at right arm 120/70 mmHg, left arm 120/80 mmHg, right leg
130/60 mmHg, and left leg 140/60 mmHg. BP was then monitored hourly. Cranial CT scan with
contrast was suggested. Neurology specialist started Citicoline 500mg IV every 12 hours and
requested Plain Cranial CT scan. Patient was seen and examined by an Intensivist at the
emergency room. An order to shift Ranitidine to Omeprazole 40 mg IV OD and
Diphenhydramine 50 mg IV every 8 hours was done. Patient was requested for stool
examination with fecal occult blood test. A referral to Allergologist was also done for further
evaluation and co-management in which patient was seen and examined at the emergency
room with orders to have standby Epinephrine 0.3 ml IM for recurrence of urticaria and
difficulty of breathing and additional laboratories of TSH, T3, T4, ANA, anti-DSDNA and
Erythrocyte Sedimentation Rate. Additionally for stool examination with Kato-Katz at
Schistosomiasis Research and Training Laboratory. Serum potassium showed 3.08 mmol/L.
Hypokalemia correction was started with IV correction at KIR of 0.2 mEq/kg/hr. Patient was then
wheeled to the PICU. At the intensive care unit, patient was seen and examined by main service
with orders to have quantitative input and output monitored and blood sugar every 12 hours
while on nothing per orem. Oxygen support was decreased to 2LPM via nasal cannula at 97%
saturation. 6 hours after admission, patient was now awake, alert, conversant with Glascow
coma score of 15 (E4V5M6). No slurring of speech noted. There was absence of urticarial lesions
and skin was not flushed. Vital signs were as follows; blood pressure 130/60mmHg, heart rate of
114 bpm, respiratory rate at 21 cpm and temperature of 37C. Motor strength still at 3/5 score.
Started on Cefuroxime 1,500mg/ dose every 8 hours and Salbutamol nebulization every 6 hours
for treatment of left basal pneumonia. Patient’s feeding was resumed with soft, hypoallergenic
diet. Hypokalemia correction was continued for another cycle.

Laboratory workup was done with the following results:

CBC PC Hgb Hct RBC WBC Neutrophils Lymphocytes Monocytes Eosinophil Basophil Platelet
count
7/27/23 160 0.47 5.84 7.93 0.82 0.10 0.08 0.00 0.00 308

Serum Sodium Potassium Chloride Ionized

Electrolytes Calcium
7/27/23 137.6 3.08 100.9 1.15
mmol/ mmol/L mmol/L mmol/L
L

Creatinine BUN SGPT/ALT T4 TSH ANA ESR

 Normal 44.2- 2.5- <50 0-
values 93.7umol/L 6.4mmol/L 10mm/hr
7/27/2 75.44 4.14mmol/L 34.40 122.03 1.27 negative 5mm/hr
3 umol/L U/L nmol/L uIU/ml
Urinalysis Color Transparency pH Specific Glucose Protein WBC RBC Epithelial Bacteria Mucus Amor
gravity cells Thread urate
7/27/23 Amber Slightly hazy 6.0 1.020 Negative Negative 2-5 1-2 Rare Few Few Few

7/27/23 CHEST XRAY APL PORTABLE

Result Left Basal Pneumonia

7/27/23 CRANIAL CT SCAN WITHOUT IV CONTRAST

Result No acute intracranial hemorrhage, territorial infarction, mass lesion, cortical
dysplasia, abnormal extra-axial fluid collection, hydrocephalus nor midline shift
The Hippocampi are symmetrical with no evidence of abnormal densities. No
neuronal migration abnormality is noted.
Mild bilateral maxillary, bilateral sphenoid and bilateral ethmoid sinusitis.

7/27/23 WHOLE ABDOMINAL ULTRASOUND

Result Top normal size liver with fatty infiltration grade I-II. No focal mass.
Normal sized gallbladder with 8 pieces gallbladder polyps of 0.2 cm in sizes but no
cholecystitis.
Mild splenomegaly with splenic index of 1,064
Normal size kidneys with at least 2 pieces sandy crystals of less than 0.2 cm in
sizes
No hemiperitoneum, no hemothorax and no hemopericardium
No pleural effusion, no pericardial effusion and no free intra-abdominal fluid
Normal sonogram of the pancreas, ureters, urinary bladder and prostate gland
No intraabdominal mass or abscess
Unremarkable abdominal aorta, inferior vena cava, iliac artery and vein

HOSPITAL DAY 2 (7/28/23)

S- Patient had apparent disappearance of symptoms until prior to eating breakfast, experienced
recurrence of urticarial rashes on the face, chest and back was noted, associated with
generalized body weakness, slurring of speech and occasional cough, nonproductive. No
difficulty of breathing, no syncope, no seizure, no chest pain, no abdominal pain, nor vomiting
noted.

O- Vital signs were as follows: Blood pressure of 126/58mmHg, heart rate at 93bpm, respiratory
rate of 13 cpm, afebrile at 37.5C with 98% O2 saturation at 2LPM O2 support. Skin was flushed,
with urticarial lesions and angioedema of lips and eyelids. Patient had clear breath sounds on
auscultation. No stridor nor wheeze noted. The Glascow Coma Score remained at 15. Patient
was conscious, coherent, conversant and follows command. Intact short- and long-term
memory. No preferrential gaze. No facial asymmetry, tongue at midline and responsive to verbal
stimuli. Motor strength at score of 2/5, active movement only when gravity is eliminated.

A- Biphasic Anaphylaxis secondary to Food Intake;

Transient Ischemic Attack;
Pediatric Community Acquired Pneumonia-C;
Hypokalemia, Secondary;
Hypertension Stage 1

P- F: AR 1L + KCl 10 mEqs (FMR)

R: Noted cough, nonproductive; no DOB
Symmetrical chest expansion, crackles, bilateral, no retractions
98% O2 saturation at 2LPM O2 support
I: Febrile episodes Tmax 39.8C
Cefuroxime 4.5gm/day (Day 1+1)
C: Captopril 25mg OD started
For 2D echocardiogram with doppler studies
H: Repeat CBC platelet count with Dengue Rapid Test, Lipid Profile
M: Repeat serum electrolytes determination
Kcl correction incorporated 10mEqs to IVF
CBG 100mg/dL
O: Negative fluid balance I: 3,027 O: 4,050
UO 2.6 cc/kg/hr
N: GCS 15
Tongue midline, No facial asymmetry
Citicoline 1gm/day (Day 1+1)
D: Soft, hypoallergenic diet
Given Epinephrine 0.3 mg IM stat dose
Started Bilastine 20mg OD 1 hour after dinner
Stated Ebastine + Betamethasone tab OD
Daily food diary

6 hours after recurrence of anaphylaxis symptoms, patient was conscious, coherent and
conversant. Still with occasional cough, nonproductive. No syncope, no abdominal pain, no
nausea, no vomiting, no slurring of speech, no chest pain, no difficulty of breathing, no fever, no
headache nor dizziness. Vital signs were stable at blood pressure of 119/57mmHg, heart rate of
77 cpm, respiratory rate of 18 cpm and 98% O2 saturation on 2LPM oxygen via nasal cannula.
Skin was not flushed. No urticarial lesions nor angioedema noted but dermatographism after
skin stroking was elicited. There were crackles upon lung auscultation. No wheezes nor
retractions. Patient had warm extremities, full equal pulses and motor strength at score of 4/5,
active movement against gravity. Oxygen support was then discontinued without episodes of
desaturation.
 CBC PC Hgb Hct RBC WBC Neutrophils Lymphocytes Monocytes Eosinophil Basophil Platelet
count
7/27/23 160 0.47 5.84 7.93 0.82 0.10 0.08 0.00 0.00 308
7/28/23 145 0.43 5.23 7.21 0.77 0.15 0.08 0.00 0.00 223

Serum Sodium Potassium Chloride Ionized

Electrolytes Calcium
7/27/23 137.6 3.08 100.9 1.15
mmol/ mmol/L mmol/L mmol/L
L
7/28/23 137.9 3.26 104.9 1.19

T3 T4 TSH
Normal 0.92- 66-181 0.27-
values 2.33 4.20
7/27/23 122.03 1.27
nmol/L uIU/ml
7/28/23 1.2
nmol/L
FOOD DIARY Breakfast Lunch Dinner
Date
7/28/23 “Lugaw” (porridge) “Lugaw” (porridge), Rice and burger steak
and ground meat soup

HOSPITAL DAY 3 (7/29/23)

S- Patient still had occasional nonproductive cough associated with occasional abdominal pain
but with no recurrence of syncope, slurring of speech, urticarial rash nor angioedema. No
pruritus, febrile episodes nor difficulty of breathing were experienced.

O- Vital signs were as follows blood pressure of 118/66mmHg, heart rate of 61bpm, respiratory
rate at 15cpm, temperature of T36 oC with oxygen saturation of 98% at room air. Skin was not
flushed. There was absence of urticarial lesions. Lips and eyelids were not swollen. The chest
had symmetrical chest expansion with decreased crackles at the left lung fields, no wheezes nor
retractions. Abdomen was flat, soft and nontender. The extremities were grossly normal.
Regained motor strength at 5/5. Glascow coma score of 15. Patient was oriented, cooperative,
conversant and speaks dialect fluently.

A- Anaphylaxis secondary to Food Intake;

Transient Ischemic Attack;
Pediatric Community Acquired Pneumonia-C;
Hypokalemia, Secondary;
 Hypertension Stage 1

P- F: AR 1L + KCl 10 mEqs (FMR)

R: Noted cough, nonproductive; no DOB
Symmetrical chest expansion, decreased crackles, left lung fields, no wheeze, no
retractions
98% O2 saturation at room air
I: No febrile episodes
Cefuroxime 4.5gm/day (Day 2)
C: Normal rate, regular rhythm
Increased Captopril to 50mg/day BID
H: No bleeding
M: Kcl correction incorporated 10mEqs to IVF
O: Positive fluid balance I: 1,999 O: 1,370
UO 1.13cc/kg/hr
N: GCS 15
Tongue midline, No facial asymmetry
Citicoline 1gm/day (Day 2+1) then discontinued
D: Diet as tolerated
May trans-out to regular room
Discontinued Diphenhydramine
Standby Epinephrine 0.3 mg for anaphylaxis recurrence
Bilastine 20mg/tab, one tab OD 1 hour after dinner
Ebastine 10mg+ Betamethasone 500mcg/ tab, one tab OD
Daily food diary

FOOD DIARY Breakfast Lunch Dinner

Date
7/28/23 “Lugaw” (porridge) “Lugaw” (porridge), Rice and burger steak
and ground meat soup
7/29/23 “Lugaw” (porridge) Rice and ground pork
and stewed pork

Clinical Total Triglycerid HDL LDL VLDL

Chemistry Cholesterol e Cholesterol Cholesterol
7/29/23 3.68 1.08 0.87 2.32 0.50
mmol/L mmol/L mmol/L mmol/L mmol/L
(Low)

7/29/23 Pediatric Echocardiography and Color Flow Doppler

Mitral Regurgitation; Tricuspid Regurgitation
Immunology Anti-
dsDNA
7/29/30 11.7

Clinical Fecalysis Fecal Occult

Microscopy Blood Test
7/29/30 Yellow, soft, RBC 0-2, WBC 0-2, No Negative
intestinal parasites seen

HOSPITAL DAY 4 (7/30/23)

S- Patient still had occasional nonproductive cough associated with occasional abdominal pain
but with no recurrence of syncope, slurring of speech, urticarial rash nor angioedema. No
pruritus, febrile episodes nor difficulty of breathing were noted.
O- Vital signs were as follows blood pressure of 110/80mmHg, heart rate of 68bpm, respiratory
rate at 19cpm, temperature of T36.7oC with oxygen saturation of 99% at room air. Skin was not
flushed. There was absence of urticarial lesions. Lips and eyelids were not swollen. The chest
had symmetrical chest expansion with decreased crackles at the left lung fields, no wheezes nor
retractions. Abdomen was flat, soft and nontender. The extremities were grossly normal.
Regained motor strength at 5/5. Glascow coma score of 15. Patient was oriented, cooperative,
conversant and speaks dialect fluently. Patient was then discharged with improved condition.

A- Anaphylaxis secondary to Food Intake;

Transient Ischemic Attack;
Pediatric Community Acquired Pneumonia-C;
Hypokalemia, Secondary;
Hypertension Stage 1
Gallbladder Polyp

Q-
F: Heplock
R: Noted decreased cough, nonproductive; no DOB
Symmetrical chest expansion, decreased crackles, left lung fields, no wheeze, no
retractions
98% O2 saturation at room air
I: No febrile episodes
Cefuroxime 4.5gm/day (Day 3)
C: Normal rate, regular rhythm
Captopril to 50mg/day
H: No bleeding
M: No electrolyte imbalance
 O: Positive fluid balance I: 1,460 O: 920
UO 1.0 cc/kg/hr
N: GCS 15
Tongue midline, No facial asymmetry
D: Low salt, low fat diet with avoidance of known allergens
Daily food diary
For Kato Katz as OPD

Home Medications:
1. Ebastine + Betamethasone 10mg/ 100mcg tab (Co-Aleva), 1 tab for 3 days
more
2. Captopril 25mg/tab, 1 tablet BID
3. Cefuroxime 500mg/tab (Cimex), 1 tablet every 12hours for 5 more days
4. N-Acetylcysteine 600mg/tab, 1 tab ODHS for 3 days
5. Bilastine 20mg/tab (Bilaxten) OD for 1 month
6. Epinephrine 0.3 mg IM as emergency medication for recurrence of
anaphylaxis

FOOD DIARY Breakfast Lunch Dinner

Date
7/28/23 “Lugaw” (porridge) “Lugaw” (porridge), Rice and burger steak
and ground meat soup
7/29/23 “Lugaw” (porridge) Rice and ground pork
and stewed pork
7/30/23 “Lugaw” (porridge) Rice and stewed pork

Final Diagnosis:

Anaphylaxis secondary to Food Intake;

Transient Ischemic Attack;
Pediatric Community Acquired Pneumonia-C;
Hypokalemia, Secondary;
Hypertension Stage 1
Gallbladder Polyp