History (H)
Chief Complaint: Difficulty breathing, widespread rash, and lightheadedness following shellfish ingestion.
History of Present Illness (HPI):
Mrs. Linda Carter is a 52-year-old female who arrived via EMS after experiencing acute respiratory distress, widespread rash, and dizziness shortly after eating shellfish at a restaurant. She reports that symptoms developed within 10–15 minutes of ingestion and worsened rapidly. She denies prior history of anaphylaxis. EMS administered oxygen during transport.
Past Medical History (PMH):
Hypertension (well-controlled with medication)
Seasonal allergic rhinitis
No known food allergies documented prior to this event
Past Surgical History (PSH):
Appendectomy at age 17
Tubal ligation at age 34
Family History (FH):
Father: Hypertension, deceased at 70 (MI)
Mother: Allergies and asthma
No known hereditary anaphylactic disorders
Social History (SH):
Occupation: Middle school teacher
Lives with spouse; two adult children
Denies smoking, alcohol, or drug use
No recent travel or illness
Allergies:
Seasonal allergies (pollen, dust); no previously known food allergies
Medications:
Lisinopril 10 mg PO daily
Loratadine 10 mg PO PRN for seasonal allergies
Physical Examination (P)
Physical Examination (P)
Vital Signs:
BP: 85/50 mmHg
HR: 125 bpm
RR: 28/min, labored
Temp: 98.7°F
O2 Sat: 88% on room air
General Appearance:
Appears anxious and restless. Mildly diaphoretic. Speaking in short phrases.
HEENT:
Swelling of lips and tongue noted. Mucous membranes moist. No visible cyanosis.
Cardiovascular:
Tachycardic, regular rhythm. Peripheral pulses weak and thready.
Respiratory:
Audible wheezing bilaterally. Labored breathing. Substernal retractions noted. Diminished breath sounds at bases.
Gastrointestinal:
Abdomen soft, non-tender. No nausea or vomiting reported.
Neurological:
Alert and oriented x3, but lightheaded and slightly disoriented during episodes of hypoxia.
Skin:
Generalized urticaria (raised, erythematous rash) on torso, arms, and legs. No blistering or open wounds.