Hilary Ong, MD, Children’s National Medical Center

HPI:8mo exFT Fwith history of wheezing brought in for respiratory distress and epistaxis. She was in her usual state of health when she woke up crying from sleep. Mom found her in her crib, with blood from her nose and she was breathing fast. Mom denies that her child has had any fevers or upper respiratory infectious symptoms or trauma. She had been feeding wella nd went to bed at her usual  time after a feeding.

En route with EMS, pt was given albuterol neb treatment for wheezing and increased work of breathing and was on 10L FM, O2 sat 100%

ROS:

Constitutional: Denies fever  

Skin:  Denies rash, edema or bruising

ENMT: +Epistaxis, Denies nasal congestion or rhinorrhea

Respiratory: +Shortness of breath, Denies cough, stridor, cyanosis, apnea or wheezing

Cardiovascular: Denies syncope

Gastrointestinal: Denies, vomiting, diarrhea or constipation

Genitourinary: Denies hematuria, or discharge

Neurologic : Denies seizures or weakness

Hematologic: Denies bleeding tendency

PMH: Wheezing

Medications:  None.

Social history: Lives with parents and toddler-age sibling

Vaccinations: UTD

PE: T 35.5 HR 172  RR52 BP 118/101 SaO2 98% on 10L  FM  (Wt 10kg)

General:  Alert.  Respiratory distress.

Skin:  Warm.  Dry.  Intact.  No pallor.  No rash. No Bruising

Head: Normocephalic. Atraumatic

Neck:  Supple. Trachea midline .  

Eye:  Normal conjunctiva, PERLA, EOMI

Ears, nose, mouth and throat:  Dried blood over bilateral nares. Tympanic membranes clear.  Oral mucosa moist.  Secretions pink-tinged

Cardiovascular:  + Tachycardia. Regular rhythm.  2+ radial pulses. Cap refill ~3-4 sec 

Respiratory:  Tachypneic with severe retractions. Grunting. Head bobbing. Coarse breath sounds bilaterally. Good aeration throughout. No wheezing.

Gastrointestinal:  Abdomen distended, tympanic. Soft. Hypoactive bowel sounds. Hepatomegaly +2FB below costovertebral margin

Musculoskeletal:  Moves all extremities

Neurologic: Alert, fussy, non-focal neurologic examination

Sepsis alert was called. Patient was immediately placed on 15L/min HFNC 50% FiO2. RT suctioned pink-tinged secretions. NS bolus 20cc/kg given. Ceftriaxone and vancomycin given.

VBG pH7.2 CO2 58 HCO3 25 CBC, CMP, blood culture drawn , UA and urine cx pending                  

 She has no changes in respiratory distress 15mins later. She was then transitioned to Bipap 18/7 50% Fio2, with O2 sat 97%,

Anesthesia successfully intubated but noted pink-tinged frothy secretions in airway. CXR confirmed tube placement, and bilateral patchy infiltrates, no cardiomegaly, no bony abnormalities. Patient continued on high vent settings, then had desaturation 80%. Despite maximal settings on ventilator, tube confirmation upon DL, trial with BVM off vent, she had persistent desaturations to 80%. OG with coffee-ground output, and abdomen continued to be distended. She was deemed unstable to transfer to PICU from ED.

Labs significant for Hgb 7, WBC and platelets WNL, hypernatremia (Na 147), hypocalcemia (Total Ca 6.5), Bun/Cr  30/0.4, UA with microscopic hematuria

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