Mr Anaphylactic Susp Food

8/11/2019 Mr Anaphylactic Susp Food

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Morning Case reportFebruary 16th 2012


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IDENTITYName : IMS

Age : 41 years oldSex : MaleAddress : Br. Kukuh Kajan Kerambitan

Tabanan

Ethnicity : Balinese

Religion : HinduNo. RM : 14041973Time of coming : 1.40 pm


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ANAMNESISChief Complaint : Swollen eyes Present History :

Patient came with chief complaint of swollen and reddish eyes 30 minutesBATH.Around 5 hours BATH the patient took 1 tablet of paracetamol and onetablet of sodium diclofenac due to muscle cramp.Patient also complained hard to breath.He also complained about swollen and watery secrete on both of his eyeswhich begin 15 minutes after he ate babi guling for his lunch . There were

no accompanying factors that could have worsened or relieved hiscomplains.This complain was disturbing that he felt he couldnt do h is daily activities.

patient had a history of the same complain 3 months ago and he wasadmitted in RS Sanjiwani due to consumption of Antalgin and was observedin emergency department until symptoms improved.


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Anamnesis : Past History

History of drug allergy was found 3 months ago.

History of asthma, DM, hypertension, heart disease, dermatitisatopic or rhinitis allergic was denied by the patient.


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Anamnesis : Family history

There was no similar complains from the patients family.

There were no history of DM, hypertension, heart diseaseamong his family members.


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Anamnesis: social history

Patient is a civil servant.History of alcohol consumption and smoking was denied by thepatient.


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Physical Exam. ..

Eyes : pale conj.(-/-), yellowish sclera (-/-), pupil reflex (+/+) isochoric, Oedem

palpebrae (++/++). watery (+/+)ENT : Tonsil, Pharynx, tongue WNLNeck : JVP PR + 0 cmH2OThorax : Symmetry

HEART Insp : ictus cordis not visible Palp : ictus cordis not palpable Perc : UB: ICS II, RB: PSL D, LB: 1 cm lateral to left MCL Ausc : S1S2 single regular murmur (-)

LUNG Insp : symmetrical (static and dinamic) Palp : tactile fremitus N/N Perc : sonor/sonor Ausc : Vesicular +/+; ronchi -/-; wheezing +/+ -/- after 15 minutes

Status Present


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Abdomen : Insp : distention (-), maculopapular erythema (-) Ausc : bowel sounds (+) normal Perc : Tympani

Pal : Tenderness (-)Hepar : non-palpablelien : non-palpable

Extremities : warm +/+; edema -/-+/+ -/-


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Complete Blood Count

Abdomen: Insp : distensi (-)Ausc : Bowel sound (+) normalPalp : H/L not palpable

tenderness(-)Ballotment (-)

Perc: Tympani (+)

Extremity: pitting edema , warm- -- -

+ +

+ +

Parameter Result Unit Remarks Referencerange

WBC 3,68 10 3 / L L 4,10 11,0

-Ne 2,43 67,9 % 10 3 / L L 2,5 7,5

-Ly 0,632 17,7 % 10 3 / L L 1,0 4,0

-Mo 0,384 10,7 % 10 3 / L 0,100 1,2

-Eo 0,101 2,83 % 103/ L 0,0 0,5

-Ba 0,030 0,843 % 10 3 / L 0,0 0,1

RBC 5,45 10 6 / L 4,50 5,90

HGB 15,8 g/dL 13,50 17,50

HCT 48,1 % 41,0 53,0

MCV 88,2 fL 80,0 100,0MCH 28,9 pg 26,0 34,0

MCHC 32,8 g/dL 31,0 36,0

RDW 11,7 % 11,6 14,8

PLT 162,0 10 3 / L 150 440

MPV 6,78 fL L 6,80 10,0


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Blood Chemistry Panel

Parameter Result Remarks Reference rangeSGOT 18,9 11 33

SGPT 15,5 11 50 Albumin 3,82 3,4 4,8BUN 9 8 23Creatinin 1,1 0,7 1,2BS 106 70,00-140,00

Uric acid 6,8 2,0 7,0


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ECG

Sinus rhytm, HR 83 x/mntAxis NST elevation (-)

ST depression (-)~ NSR


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AssessmentAnapylatic reaction ec. Susp food dddrug


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THERAPY

HospitalizedO2 3Lpm

Adrenaline 0.3cc IM evaluation after 15 minutesDiphenhydramine 10mg IVMethylprednisolone 2 x 62.5mg IV

IVFD NS 0.9% 20dpmDiet 2100 kcal / day


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THERAPY

Diagnostic Planning :IgE total

Monitoring:

Vital SignsComplaints


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THANK YOU

Mr Anaphylactic Susp Food

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