I.

Introduction/ Overview of the Disease

• Anaphylaxis causes the immune system to release a flood of chemicals that can
cause you to go into shock — blood pressure drops suddenly and the airways
narrow, blocking breathing. Signs and symptoms include a rapid, weak pulse; a
skin rash; and nausea and vomiting. Common triggers include certain foods, some
medication
• There were 300 patients with anaphylaxis seen at the Philippine national tertiary
hospital from 2015 to 2019. Of the 300 patients, 179 were female (57.9%). The median
age of the patients was 26 years old, with an interquartile range of 33 years. Only 75
patients (25%) had a past history of allergic disease. Majority of the patients (70%) had
comorbidities.
• Drugs were the most common trigger of anaphylaxis (81.3%). Antibiotics were the most
common type of drugs implicated (27%). Serious outcomes were noted in a total of 31
patients (10.3%)
• In the Philippine national tertiary hospital, the incidence of anaphylaxis increased by
240% in the past decade. Predictors of serious outcome in anaphylaxis include
increased age and presence of cofactors such as beta-blocker use and presence of acute
infection.
I. Introduction/ Overview of the Disease

• Risk Factors
II. Clinical Summary/ Abstract
• PERSONAL DATA:
• Name : Roderick Gando Abella
• Age : 52
• Address : Radio Pantoc Barangay 10, Lucena City
• Gender : Male
• Status : Single
• Religion : Roman Catholic
• Work : Licensing Officer II at Lucena Government Complex
• Cc : Vomiting for 2 days
• AP : Dr. Erwin Reyes- Pulmonologist
II. Clinical Summary/ Abstract
• Events leading to consultation:
-Vomiting for 2 days
Vital Signs taken at ER MCDGH
T: 40
P: 101
R: 30
BP:Unapreciated
History of Past medical Illness
• Known Diabetic type 2 (Non-Compliant to medications)
• No Known allergies
• Occasional Alcohol intake

• Covid Vaccines:
• AstraZeneca: May 20, 2021 Booster- AstraZeneca: December 29, 2021
July 26, 2021 Pfizer: July 29, 2022
History of Present Illness
• Nov. 8, 2022
• Patient came home from work earlier that usual, no complaint. Able to eat dinner Dinuguan. After eating dinner, (+)
vomiting 3-4x, no meds taken, (+) abdominal pain
• Nov. 9, 2022
• Persistence of abdominal pain, (-) vomiting but with LBM, approximately 3-4x/ day. Able to eat lunch. Noted to have
facial edema.
• Around 8pm, with progression of edema, (+) generalized rashes noted, with decrease level of sensorium, GCS 8
(E2,V1,M5), (+) DOB
• At Emergency Room
• Still GCS 8, Bp unappreciated, HR: 101, RR: 30, T: 40, O2 Sat: 70% at room air, Hooked to O2 via NRM at 5-10 LPM
• (+) angioedema (+) rashes on face
• Epinephrine 0.3ml IM, Diphenhydramine IM, Hydrocortisone 250mg IV- GIVEN
• Dobutamine and Norepinephrine drip started- BP: 70/40, Standby Intubation– Admitted to ICU
• Admitted to ICU
• 1am GCS 13 (E3,V4,M6), BP: 70/40, titrated Norepi and dobu. Still with facial edema
• Noted elevated CKMB: 105 Trop I: 495.20 Na: 118– ACS protocol done Aspirin 80mg 4 tabs, Clopidogrel 75mg tab 4 tabs,
Enoxaparin 0.44cc SQ OD
• RBS persistently High
III. Assessment
PHYSICAL ASSESSMENT:
• Stretcher GENITOURINARY:
CONSTITUTION: • (-) Discharge
• Fever NEUROLOGIC:
SKIN: GCS: 8
• Rashes Eye Opening : 2
• Erythema Verbal Response : 1
• Angioedema Motor Response : 5
• Fair skin turgor
RESPIRATORY:
• Decreased breath sound
• Labored in breathing
CARDIOVASCULAR:
• (-) Murmur
GASTROINTESTINAL:
• Nausea and vomiting
ANATOMY
PATHOPHYSIOLOGY
 Anaphylactic Shock

Sensitization
Immunologic

Allergen B-cells IGE Mast

Antibodies Immunoglo Cells
creating bulin
cells protein
That
reacting to
allergen
 • Anaphylactic Reaction
(immunological)

Orally Ingestion
(Dinuguan)

• Anaphylactoid Reaction
(non-immunological)
Diagnostic/Lab Exams/Tests
Laboratory Indication
Tests
Complete • Lipase is the preferred laboratory test for diagnosing acute pancreatitis, as it
Blood Count is the most sensitive and specific marker for pancreatic cell damage.
(CBC) Additional laboratory testing, such as complete blood count (CBC) and
lactate dehydrogenase (LDH) tests, are useful to obtain prognostic
information.
Chest X-Ray • An ultrasound of your abdomen will show the pancreas and the surrounding
area, including your liver. It can show if a tumor is present and its size

Whole • An ultrasound of your abdomen will show the pancreas and the surrounding
Abdomen area, including your liver. It can show if a tumor is present and its size
Ultrasound
Diagnostic/Lab Exams/Tests

Laboratory Tests Indication

PT (Prothrombin Test to evaluate blood clotting

Time)

Creatinine High serum creatinine is a well-known unfavorable prognostic parameter in acute

pancreatitis.
Sodium A sodium blood test is a routine test that allows your doctor to see how much sodium is
in your blood. It's also called a serum sodium test. Sodium is an essential mineral to
your body. It's also referred to as Na+. Sodium is particularly important for nerve and
muscle function.
Potassium Electrolyte abnormalities seen in pancreatitis are often associated with dehydration, prolonged
vomiting, and calcium deposits in pancreatic fat. Serum potassium and BUN elevations may
suggest hypovolemia and should be monitored and treated with fluid resuscitation and electrolyte
replacements if indicated
Serum lipase is now the preferred test due to its improved sensitivity, particularly in alcohol-
Diagnostic/Lab Exams/Tests

Complete Blood Count Hemoglobin 13.0- Normal

  18.0  • Elevated HGB suggest lung disease, polycythemia –
• increase in the no. of RBS in the body (increases the
Date: Nov. 9, 2022 Result: 16.30
risk of other health issues, such as blood clots, heart
Nov. 12, 2022 Result: 15.30
attack and strokes
  • Decreased HGB. level suggest iron deficiency, excessive
blood loss, or over hydration
  Hematocrit 40-50 Normal
Date: Nov. 9, 2022  Result: 45.80   • Decreased HCT suggest iron deficiency anemia,
Nov. 12, 2022 Result: 43.8 excessive fluid intake, or blood loss
 Sx of low HCT:
 Pale complexion, weakness, fatigue, low energy,
trouble breathing, irregular heart beat (manifested to
patient)
• Increased HCT suggests severe Dehydration and
polycythemia
 
Diagnostic/Lab Exams/Tests

Red blood cell 4.5-6.2 4.5-6.2 Slightly decreased

(erythrocytes)
• Increased RBC Indicate polycythemia
 Date: Nov. 9, 2022 • Decreased RBC indicate VIT. B6, B12 or Folate Deficiency, it
also signifies internal bleeding, kidney disease, or
Nov. 12, 2022 malnutrition
 

MCV 79.0-92.2 79.0-92.2

(MEAN CORPUSCULAR Is a measure of the average volume of red blood cells corpuscle
VOLUME)
• Increased MCV indicate macrolytic anemia
Date: Nov. 9, 2022 • Decreased MCV indicate iron deficiency anemia
 
Nov. 12, 2022
 
MCH 25.7-32.2 25.7-32.2 Normal
(MEAN CORPUSCULAR     • Low MCH indicates Fe deficiency anemia, & rare cases low
HGB) MCH caused by a genetic condition called thalassemia –
Date: Nov. 9, 2022 limited production of HGB.
• High MCH can often be caused by anemia due to B12 &
Nov. 12, 2022 folate deficiency.
   
 MCHC 32.3-36.5 33.20 Normal
(MEAN • Low MCHC indicates Hypochromic micro lytic anemia
CORPUSCULAR HGB • High MCHC indicates dehydration or concentrated RBC
CONCENTRATION)  
 

RDW (red cell 11.6-14.4 13.90 Normal

distribution width)
• it could be an indication of a nutrient deficiency, such as a
deficiency of iron, folate, or vitamin B-12
• Decreased RDW indicate microcytic anemia

White blood cell 4.0-10.0 8.04 Normal

    • Elevated WBC indicates infection, abnormal Bone marrow,
smoking, chronic lung disease, immune disorders,
inflammatory or allergic reactions or even physical and
emotional stress
• Decreased WBC indicates lupus, rheumatoid arthritis,
vitamin deficiencies, or a side effect of cancer treatment
Neutrophil 55-65 61 Normal findings
(Fight pyogenic • Neutrophilia- indicates infection
infection) • Low Neutrophil- Neutropenia- is a condition that means low
  level neutrophils, may be due to an infection eg. (Bacterial
pneumonia)
 

Lymphocytes 25-35 26 Normal findings

(fight viral infection) • Lymphocytopenia – low lymphocytes indicate a possible
(produce antibodies infection
against bacteria, • Increased lymphocytes indicate Infection (bacterial, viral,
viruses and other other) Cancer of the blood or lymphatic system
invaders.  
 

Monocytes 3-6 7 Normal findings

(Fight severe   • Often a response to stress, chronic infection or autoimmune
infection disease
• Decreased monocytes indicates bloodstream infection,
chemotherapy, or a bone marrow disorder
Eosinophils (fight 2-4 5 Elevated Eosinophils
allergic disorder   • High count eosinophil indicates infection
and parasitic (bacterial, virus or parasite)
infection) • Low count indicate intoxication from alcohol,
excessive production of cortisol
 

Platelet 150-450 274 Normal

  • LOW PC called thrombocytopenia indicates
blood disorder, aplastic anemia, drink a lot of
alcohol, increased risk for bleeding
• High platelet called thrombocytosis, can lead to
blood clots, and can trigger uncomfortable
symptoms, as well as medical emergencies
such as seizure & stroke.
Blood Chemistry Creatinine 0.66-1.25 0.90 • Elevated BUN level means the kidneys are not functioning well. But elevated
BUN can also be due to dehydration, resulting from not drinking enough fluids
  or for other reasons; urinary tract obstruction, CHF or recent heart attack.
• Decreased value may be caused by a diet very low in protein, by malnutrition,
April 07, 2022 or by severe liver damage.

  Sodium 137-145 140 • Hypernatremia can cause fluid retention (edema)

  S/Sx: Muscle weakness, restlessness, extreme thirst, confusion, lethargy,
irritability, seizure and unconsciousness
• Hyponatremia can cause rapid brain swelling, more common in CHF
 S/Sx: N/V, HA, confusion, loss of energy, drowsiness, & fatigue, muscle
weakness, spasm or cramps, seizure & coma
 

  Potassium 3.5-5.1 3.20 • A high potassium can make your heart beat irregularly, which in the worst
cases can cause heart attack.
• A low potassium level can make muscles feel weak, cramp, twitch, or even
become paralyzed, and abnormal heart rhythms may develop.

Lipase 23-300 65 • Normal

-Elevated may mean pancreatitis or another type of pancreas disease
-Decrease value may mean there is damage to cell of pancreas that produce lipase,
it happens in certain chronic disease such as cystic fibrosis
 ABG
RESULTS NORMAL RANGE
PH 7.49 7.35-7.45
PCO2 14.4 35-45
P02 80 80-100 mmHg
HCO3 11.1 22-26 meq/L
BE -12 +/- 2
TOTAL C02 11
02 SAT 97% 95-100
FI02 32%

Pulmonary alkalosis
            
GENERIC NAME SPECIFIC INDICATION CONTRAINDICATION SIDE EFFECT NURSING
BRAND NAME ACTION RESPONSIBILITIES
DOSAGE
FREQUENCY
EPINEPRINE
0.3ML IM
STAT
DIPHENHYDRAMINE
IM
STAT
HYDROCORTISONE
250MG IV
STAT
ATROVENT NEB
Q4

OMEPRAZOLE
(PROSEC)
10mg IV
ASPIRIN
80mg 1 TAB
OD
CLOPIDOGREL
75mg 1 TAB
OD
            
GENERIC NAME SPECIFIC INDICATION CONTRAINDICATION SIDE EFFECT NURSING
BRAND NAME ACTION RESPONSIBILITIES
DOSAGE
FREQUENCY
ATORVASTATIN
80mg 1 TAB
ODHS
ENOXAPARIN 0.4CC
SQ
OD
PARACETAMOL
(BIOGESIC)
300mg IV
Q4 PRN FOR FEVER
TRIMETAZIDINE
35mg 1TAB
BID
HEMOSTAN
500mg IV
Q8
VITAMIN K
1 amp
Q8 X 3 DOSES
VIATREX
1gm IV
Q12
            
GENERIC NAME SPECIFIC INDICATION CONTRAINDICATION SIDE EFFECT NURSING
BRAND NAME ACTION RESPONSIBILITIES
DOSAGE
FREQUENCY
CLINDAMYCIN
900MG IV
Q8
CEFAZOLIN
2gm IV
Q24
Nursing Care Plan
Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Assess patient’s level of Facilitates planning of After of an hour of nursing

Subjective: Knowledge After an hour of understanding preoperative teaching program,
intervention patient report
deficit related to nursing identifies content needs
“Kinakabahan ako decreased fear and anxiety
unfamiliarity intervention,
sa maaring Provides knowledge base from reduced to a manageable
with the patient will
mangyari sa akin which patient can make level
information Report decreased Review specific pathology and informed therapy choices and
dahil hindi ko
alam ang maaring resources prior fear and anxiety anticipated surgical procedure. consent for procedure, and
Verify that appropriate consent has presents opportunity to clarify Evidenced by:
kalabasan nito” to surgical reduced to a
been signed misconceptions Verbalize understanding of
as verbalized by procedure manageable level
secondary to Enhances patient’s
disease process,
the patient understanding or control and perioperative process and
pancreatic cystic
Objective cues: neoplasm can relieve stress related to the postoperative expectations.
Implement individualized unknown or unexpected.
Facial tension preoperative teaching program
Helps reduce the possibility of
Restlessness postoperative complications and V/S:
promotes a rapid return to BP: 120/80
Pale in normal body function. RR:22
Preoperative or postoperative
appearance O2 sat: 99%
procedures and expectations,
Cold clammy urinary and bowel changes, dietary
considerations, activity levels/ Increases likelihood of
hands successful pain management.
transfers, respiratory/ cardiovascular Some patients may expect to be
S exercises pain-free or fear becoming
addicted to narcotic agents.