Question

T.J. is a 53-year-old man that has just presented to the Emergency Department for a rash, shortness of breath and feeling very weak. He tells you that he just finished a shrimp dinner at the local restaurant when the symptoms began and they have been getting steadily worse. He states the first thing he noticed was his lips tingling and then the rest of his mouth. Over the next few minutes he continued to feel worse when his wife noticed that he was very red and flushed in appearance all over. He also noticed that his chest felt very tight and he could hear some wheezing when he would breathe. By the time he got to the ED he was unable to stand on his own due to feeling like he might faint and his wife had to come get help to get him inside. He denies ever having anything like this before but admits since he lives in central Texas he never eats shrimp and for that matter never really eats any seafood and cannot remember if he has ever had shrimp before tonight. He noted nausea on arrival to the ED and feels like he might need to have a diarrheal stool. PMH- Long history of HTN and takes lisinopril/hctz 20/25 daily. He has no history of DM or cardiac disease and no history of lung disease. PSH- is positive for an appendectomy at age 12 otherwise no surgeries. Social History- negative for tobacco use and admits to a beer just about every night. He does not use any drugs and does use caffeine in the form of iced tea and maybe one cup of coffee in the morning. Family History – Positive for HTN and heart disease as well as CVA. Vital signs 82/30, 130, 26, 99.8, O2 sats of 90%. Weight 225 PE- Alert and awake male that is slightly overweight and appears anxious and in mild distress. He does appear flushed and audible wheezing is noted when you walk in the room. Head is atraumatic and normocephalic with a normal hair distribution. Eyes PERRLA, mild conjunctival injection with corneas both clear and not muddy in appearance with no drainage from either eye. ENT lips are slightly edematous, tongue is midline, posterior oropharynx has no exudate or erythema and tonsils are normal size. Nose has no septal deviation and the turbinates are congested and slightly swollen in appearance and he sounds congested. Ears are both normal in appearance. Neck is supple with no limitation in ROM and there is no tracheal deviation. No thyromegaly and no lymphadenopathy noted. Chest is nontender with no lesions evident and has equal motion on respiration. Lungs are bilaterally diminished with wheezing across the upper fields bilaterally but no breath sounds heard across the bases bilaterally. Heart is regular with no murmurs or rubs evident, he is tachycardiac. Abdomen is soft and nontender with equal bowel sounds all quadrants. MS equal rom all extremities with equal pulses and strength. Neuro CR NV 2-12 intact, alert and awake and oriented x 3 with DTRs 2/4 and equal bilaterally, sensation is grossly intact and there are no lateralizing signs or indications. Skin is flushed red across the entire body and there are non-confluent large urticaria noted across most of the body. What is wrong with this patient? If he is having an allergic reaction what type is it? Why is the blood pressure so low? Why is the pulse rate so fast? Why does he get weak when he stands up? What are urticaria and why does this patient have them. Why is his oxygen saturation so low? Why is he wheezing? What is the most emergent treatment we need to provide for this patient? What is the first medication he should be given? Why? What other medications should he be given as well? Why is his skin red? Why is he having an upset stomach?

Answer 1

What is wrong with this patient?

The patient is affected with allergen reaction due to the intake of shrimp a kind of seafood. Skin rash, swelling of lips are the first signs of allergic reaction.

If he is having an allergic reaction what type is it?

He has a type of Anaphylaxis reaction which is a serious life-threatening situation. The patient immune system has overreacted to the allergen(food) and leads to allergic symptoms.

Why is the blood pressure so low? Why is the pulse rate so fast?

As a response to the allergen, the immune system releases large amounts of chemicals like histamine. These chemicals make the blood vessels to dilate which in turn results in low blood pressure and increased heart rate.

Why does he get weak when he stands up?

The symptoms become severe and the person feels weak. In addition, low blood pressure and fainting make the person unable to stand on its own.

What are urticaria and why does this patient have them.

Urticaria or hives is the sudden outbreak of swollen red skin rash occurs in the body parts which also leads to itching. This patient develops urticaria in response to the allergy of seafood.

Why is his oxygen saturation so low? Why is he wheezing?

IgE binding to the trigger cells in response to the allergens make the blockage of the airway and swelling of tissue cells. So while breathing, a hoarse or wheezing is produced. Lack of blood flow into the cells results in low oxygen saturation.

What is the most emergent treatment we need to provide for this patient?

Make the patient in a comfortable position. Elevate the legs. Administer oxygen. Reduce the severity of the symptoms.

What is the first medication he should be given?

Adrenaline is the first line of treatment which raises the blood pressure.

What other medications should he be given as well?

Antihistamines, corticosteroids can be used for the management of other symptoms.

Why is his skin red?

Skin becomes red due to allergen reaction which produces the protein like histamine.

Why is he having an upset stomach?

The patient is suffering from a food allergy and severe allergen reactions lead to vomiting and diarrhea.