CHIEF COMPLAINT: Allergic reaction.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male who states he accidentally ate a cookie that had peanut butter encased within it. He states he is allergic to peanut butter. He took two Benadryl, total of 50 mg p.o., before arriving. He received an albuterol nebulizer. He states he consumed it around 20 minutes before arrival of EMS. He is having complaints of throat closure, chest tightness, shortness of breath, difficulty swallowing. No chest pain. No fever or chills. The patient is being seen for allergic reaction.
PAST MEDICAL HISTORY: Depression and anxiety.
PAST SURGICAL HISTORY: Negative.
MEDICATIONS: Klonopin, Abilify, Prozac, Tofranil, Wellbutrin.
ALLERGIES: NKDA, peanut butter.
SOCIAL HISTORY: Negative.
FAMILY HISTORY: Negative.
REVIEW OF SYSTEMS: As listed in the HPI. Remainder of ROS reviewed with the patient and negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 36.2, pulse 92, respiratory rate 22, blood pressure 104/72, and oxygen saturation 97% on room air.
GENERAL: The patient is an obese male who appears nontoxic and in no acute distress. No broken sentences. No dysphonia noted.
HEENT: Eyes: Pupils are equal and reactive. Extraocular muscles are intact. Accommodation is normal. Ears: No bulge and dullness. Nose: No mucosal congestion. Mouth and Oropharynx: Laryngeal edema and moist. No tonsillar edema, no exudate noted.
NECK: Supple. No JVD, adenopathy, bruit. No meningeal signs. No rigidity, no stridor.
CHEST: Clear. No rales, rhonchi or wheeze.
CARDIAC: Regular rate and rhythm. No murmurs, clicks, heaves or gallops.
ABDOMEN: Soft, nontender, nondistended.
SKIN: He has diffuse urticaria to the trunk and upper extremities, face and neck.
NEUROLOGICAL: Alert and oriented to time, place and person. Cranial nerves II-XII intact. Normal motor, normal sensory. Grip strength equal bilaterally.
EXTREMITIES: No cyanosis, no edema, no ecchymosis. Distal pulses, cap refill 2+ and equal bilaterally.
MENTAL STATUS: No suicidal or homicidal relations. Affect normal.
EMERGENCY DEPARTMENT COURSE AND TREATMENT: The patient received Solu-Medrol 125 mg IV in the emergency room, 50 mg of Benadryl IV, Pepcid 20 mg IV, epinephrine 1:1000, 0.3 mg subcutaneous. On two-view chest x-ray, no evidence of acute cardiopulmonary process. We visualized the films and agree with this interpretation. ED panel: Venous blood gas; pH 7.38, lactic acid 1.1, glucose 242, sodium 134, creatinine 1.3, ionized calcium 1.04, troponin 0.01, hemoglobin 16.8, hematocrit 50.4. EKG: Sinus rhythm, no ST elevation or depression noted, no change compared with prior study, rate 90, PR interval 142, QRS 110, QT 348, QTc 426, P axis 80, T axis is -5. Reassessed at 2000, improved. The uvula edema has improved as well. He states that his throat tightness and difficulty swallowing have improved. No chest tightness, shortness of breath or chest pain. We repeated Solu-Medrol 80 mg IV. CK is 2. CK-MB fraction is 2. Reassessed at 2130 hours. The rash had resolved. He had no complaints of chest tightness, throat closure, wheezing or shortness of breath. Prior to discharge, the patient was given prednisone 60 mg one p.o.
CONDITION ON DISPOSITION: Stable.
DIAGNOSES:
1. Allergic reaction secondary to peanut butter.
2. Hyperglycemia.
PLAN: The patient will be discharged with family. Medrol Dosepak as instructed. Atarax 25 mg three times daily as needed, #30, EpiPen use as directed, Zantac over-the-counter 150 mg twice daily for seven days. The patient is to return to the emergency room immediately if symptoms worsen.
