Case by Jessica Hippolyte MD, CNMC PEM Fellow

8 y.o. F with seasonal and food allergies presents with 3 days of intermittent facial swelling, hives, and abdominal pain after peanut exposure. She has known food allergies to wheat, peanuts, and shellfish. 3 days ago, patient developed tongue and lip swelling and abdominal pain 1 hour after eating four peanut butter cookies. Denies hives, pruritus, wheezing, cough, dyspnea, v/d, syncope, dizziness, or altered mental status. Family couldn’t find patient’s EpiPen so gave Claritin and over few hours her symptoms improved. The following day she had no recurrence of facial swelling or abdominal pain but developed diffuse hives and pruritus. Mom treated with another dose of Claritin and hours later symptoms improved. Today she woke up with recurrence of lip and tongue swelling that have slightly improved with Claritin but 2-3 hours later developed diffuse itchy hives prompting ER evaluation. While in the waiting room she starts experiencing some abdominal pain and nausea but no vomiting or diarrhea. Endorses history of anaphylaxis to peanuts at age of 4.  Denies ever having a history with days of allergic symptoms that come and go.

ROS
Constitutional symptoms: denies fever, no fatigue or lethargy
Skin symptoms: +Rash, pruritus
CV: No palpitations, chest pain, dizziness
Respiratory symptoms: denies shortness of breath, no cough, no wheezing
Gastrointestinal symptoms: + Abdominal pain and nausea, no vomiting or diarrhea.
Neurologic symptoms: no altered level of consciousness.
MSK: No joint or muscle pain

PMH: seasonal allergies
PSH: none
Meds: Epipen, Claritin
Allergies: wheat, shellfish, peanuts
Immunizations: up to date

EXAM:
Vitals:  T 37.0, HR 111, RR 20, 117/80, 97% RA

General:  Alert.  appropriate for age.  Uncomfortable and intermittently crying.  
Skin:  Urticaria on the neck, abdomen, back, lower and upper extremities bilaterally.
Eye:  Normal conjunctiva.  no discharge. EOMI. vision grossly normal.  
Ears, nose, mouth and throat:  Oral mucosa moist.  No facial, lip, tongue swelling.  
Cardiovascular:  Regular rate and rhythm, no murmur. Normal peripheral perfusion. 
Respiratory:  Lungs are clear to auscultation.  respirations are non-labored.  breath sounds are equal.  No wheeze.  
Gastrointestinal:  Soft.  Nontender.  Non distended.  Normal bowel sounds.  
Musculoskeletal:  Normal ROM.  moves all extremities.  
Neurological:  Alert.  No focal neurological deficit observed.  normal sensory observed.  normal motor observed.  normal speech observed.  normal coordination observed.  developmentally normal.  
Psychiatric:  Cooperative