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Clinical Skills Challenge - case 5

This 24-year-old lady was admitted at 9pm with wheeze and shortness of breath. Can you make the correct diagnosis?

 

History of presenting complaint

She was at a restaurant having dinner with her partner. She had just finished her main meal of lobster when she felt generally unwell. Within 15 minutes she had become quite distressed with a wheeze and short of breath. She felt her lips tingling and become a little swollen.

On admission

This lady is terrified and distressed. She is very wheezy and has marked angio-oedema affecting her lips. Her skin is quite flushed.


Past medical history

  • Asthma as a child.

  • Appendicectomy 4 years ago.

  • Allergic to aspirin.


Table 1: Vital signs on admission

Blood pressure84/60 mmHg in both arms
PulseRate 120 per minute and regular
Respiratory rate45 per minute
Temperature36.4oC
Oxygen saturation86% on high flow oxygen

Bloods

  • Her full blood count and U&E’s were all within normal limits.

  • Arterial blood gas showed acute respiratory acidosis with hypoxia. PO2was 9.2 kPa on high flow oxygen.

Readers' comments (84)

  • It appears from the history leading up to the events that this lady is could be having an anaphylactic reaction. due to the angiodema to the lips & drop in BP and low sa02. her medical history shows she had asthma as a child & with allergy to asprin
    indicates she is hypersensitive to some substances
    1 of the common allergens is seafood & as she has consumed the lobster this seems to point to an anaphylactic reaction.
    Anaphylactic reactions are potentially fatal , but can vary in severity.
    she needs a anti-histamine & an injection of adrenaline 1:1,000
    and repeated injection. if no improvement after 5-10 mins

    Mandy Bushell Community staff Nurse

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  • anaphylactic shock

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  • severe allergic reaction to ? lobster, anaphylactic shock.

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  • in my opinion its model case of anaphylactic shock after food alergen

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  • The patient is suffering from anaphylactic shock from an allergic reaction to the lobster.

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  • From this ladies symptoms i am guessing shes having an Anaphylaxis reaction to shellfish. This would explain her tingling, wheeze and the angio-oedema affecting her lips. The Flushing would maybe be cased by the effort in trying to gain more oxygen through her breathing. Low blood pressure, high pulse rate, high respiratory rate and low 02 saturation are all common signs in anaphylaxis.

    Treatment for this condition would be the administration of 1:1000 adrenaline an adult takes 500 micrograms IM (0.5 mL), This will be done via intramuscular injection, and reapeated after 5 minutes if no improvement. An antihistamine such as Chlorphenamine (Dose 10mg IV) and a Steroid like Hydrocortisone ( Dose 200mg IV) can be given to help reduce the reaction. Also as this lady has low blood pressure, fluids such as 0.9% saline solution could be given to titrate against low BP.

    Once this lady is ready for discharge, a medi-alert braclet should be presented to the paitent to warn others of the allergen. As well as the use of an epi-pen incase of a secondary reaction. Finally allergen testing could be use to rule out other allergies, as she could be considered hypersensitive due to her history of asthma.

    Andrew Johnston
    Student Nurse

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  • Was suffering from anaphylactic shock with some complications of airway obstruction (asthmatic rection and circulatory collapse with severe hypotension.

    Treatment- intramuscular adrenaline, intravenous chlorpheniramine 10mg,high flow oxygen, intravenous fluids and intravenous hydocortisone.

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  • anaphylactic shock

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  • Due to this lady having eaten lobster and having angio odema, wheezing, shortness of breath, hypotension and tachycardia, I would suggest she is suffering from anaphylaxis.

    Caroline T.

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  • I have just enrolled on the Nursing Diploma at DMU University. Althiugh I have a limited knowledge I can identify 2 vital signs.
    Based on the evidence I would diagnose antigalatic shock. Indicators being a swollen mouth and low blood pressure.

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