Age: 5.0
Sex: F
Vaccine: FLUX
Symptoms: Vomiting
Clinical narrative: Vomiting (multiple times within an hour, Hives across entire body.  Due to multisystemic symptoms I would classify as mild anaphylaxis however due to no breathing difficulties attending physician did not agree.  Provider notes as follows: MD at 1/16/2020  6:37 AM Emergency Department Sign-Out Note   Time of transfer: 6AM   Care transferred from: Dr.    Condition at time of transfer: Stable   Brief HPI Patient is a 5 y.o. female pmh T1DM and DKA presented with N/V/ glucose 300s/ transient hives and was awaiting period of observation at the time of signout.   Please see Dr. and Dr.'s notes for initial evaluation, assessment, and plan.  Briefly, pt started on basal insulin yesterday.  Leading dx is immune stimulus.  Extremely low clinical suspicion for anaphylaxis. Received zofran w some improvement.     ED Course (since sign-out to me) UA remarkable for glucosuria and ketonuria.  Ordered DKA work-up which was extremely reassuring against DKA. Pt was observed in ED for several hours and continued hives primarily over her trunk remained but remained HS and comfortable wo other symptoms, playful and extremely well-appearing. Discharged home w return precautions and close f/u w pediatrician.   The patient was signed out to me by preceding ED team.  Please see their notes for full details.  I assumed the patient's care, reviewed the medical record, and discussed the patient's ED course with the previous treatment team.  Pertinent labs and studies have been reviewed.     MD Resident 01/16/20 1319   Electronically signed by, MD at 1/16/2020  1:39 PM MD at 1/16/2020  5:47 AM       Chief Complaint Patient presents with ? Emesis     HPI    5-year-old female previously healthy type I diabetic presenting to the emergency department with 2 episodes of nonbilious nonbloody emesis at home with episode of hyperglycemia.  Patient woke up and went to mother for not feeling well.  She vomited.  Mom noticed her sugar on her pump was in the 300s so gave her insulin per sliding scale. Pt in low 100s prior to bed. Pt broke out in hives to left UE, so mom called EMS. By the time EMS arrived, hives resolved so mom sent EMS away. Immediately after, pt again vomited a second time.    Transported to the ED by EMS. No hx of allergies. Sister in room with hx of allergies to nuts, hx of asthma. Pt without hx of asthma. Mom concerned about ?anaphylaxis given GI symptoms + temporary rash.    Allergies Allergen Reactions ? Other [Unclassified Drug] Hives     flinstones multivitamin      Review of Systems General: no fever Head: no headache Eyes: no vision changes Neck: no sore throat Cardiovascular: no chest pain Respiratory: no shortness of breath GI: + nausea, + vomiting GU: no dysuria   10 systems were reviewed and negative except where detailed above.      Physical Exam  Constitutional: She appears well-developed. No distress.  HENT:  Mouth/Throat: Mucous membranes are moist.  Eyes: Pupils are equal, round, and reactive to light.  Neck: Normal range of motion.  Cardiovascular: Normal rate, regular rhythm, S1 normal and S2 normal. Pulses are strong.  Pulmonary/Chest: Effort normal and breath sounds normal. There is normal air entry. No respiratory distress. Air movement is not decreased. She has no wheezes. She exhibits no retraction.  Abdominal: Soft. She exhibits no distension. There is no tenderness.  Musculoskeletal: Normal range of motion. She exhibits no tenderness or deformity.  Neurological: She is alert.  Skin: Skin is warm. Capillary refill takes less than 2 seconds. She is not diaphoretic.      Procedures   MDM   ED Course:       5-year-old female with history of type 1 diabetes presenting with episode of vomiting and temporary rash to upper extremity.  Patient had sugars in 300s this morning which have since improved with appropriate dosing of insulin.  Mom concerned about anaphylaxis however patient has no wheezes, no rash, no hypotension, no persistent GI symptoms. Will get UA to eval for ketones and monitor. Will give zofran for nausea. Will give benadryl for hives which have since resolved. No known food allergies. Doubt anaphylaxis given presentation.    Plan for UA, and monitor in ED with repeat exam. If persistent neg symptoms, will discharge home with close pcp f/u.    MD 01/16/20 0638