Case Management Protocol-Ong-Centipede Envenomation FINAL

PHILIPPINE CHILDREN’S MEDICAL CENTER
Quezon Avenue, Quezon City
CASE MANAGEMENT
Approach to Centipede Envenomation
12 March 2020, 8:00AM-10:00 AM
Multipurpose Hall 3rd floor
PRESENTER: CONSULTANT IN CHARGE:

Jan Winifred C. Ong, MD Elaine Dy, MD
MODERATOR: RESIDENTS IN CHARGE:

Katherine Banzali, MD Jan Winifred C. Ong, MD
Krystelle Charisse Javillo, MD
REACTOR:
Emelia B. Santmaria, MD
General Data:
This is a case of A.P., 3 year old, male, Filipino, Catholic, currently residing in
Commonwealth, Quezon City who came to our institution on December 28, 2019
Informant and Reliability: mother; good reliability
Chief Complaint: centipede bite
History of Present Illness:

Apparently well until two hours prior to consult, (8am), while playing inside the
house, the patient noted a crawling centipede on the trunk, when it suddenly bit him.
The bite has resulted to an erythematous plaque on his right nipple area. It was
noted to be tender and pruritic. There was no associated vomiting, difficulty of
breathing, nor fever. It was immediately cleansed by the mother with soap and water.
Persistence of wound erythema prompted consult.
Review of Systems
General: No weight loss, no irritability, no changes in feeding, no
decreased activity
HEENT: No eye redness or discharge, no epistaxis, no naso-aural
discharge, no oral ulcerations, no dysphonia
Cardiopulmonary: No shortness of breath, no difficulty of breathing
1
Gastrointestinal:No nausea or vomiting, no dysphagia, no abdominal pain, with
loose, watery, blood-tinged stools.
Genitourinary: No discharge, no hematuria, no oliguria, no tea-colored urine, no
dysuria, no hemorrhoids
Musculoskeletal: No joint swelling, no joint or extremity pain, no truncal obesity,
no edema
Endocrine: No polyuria, no polydipsia, no temperature intolerance
Neurologic: No headache, no increased sleeping time, no seizures
Birth and Maternal History

Born to a 19 year old G1P1 (1001) non-alcoholic beverage drinker non-
smoker mother. The mother was cognizant of pregnancy at 1 month age of gestation
and started regular pre-natal check-ups at a local health center in Quezon City and
was seen by a midwife. The mother had regular intake of multivitamins and ferrous
sulfate and claims no maternal illnesses such as diabetes and hypertension.
Ultrasound was done once at 9 months age of gestation with normal results. No
exposure to radiation and viral exanthem were noted.
The patient was delivered full term via normal spontaneous delivery at a
hospital assisted by an obstetrician, with good cry and activity upon birth. No cord
coil and no meconium-stained amniotic fluid were noted. Hepatitis B vaccine, BCG
vaccine Vitamin K and Erythromycin eye ointment were given. Newborn screen and
hearing screening were normal. The patient was discharged after 2 days, with good
suck and activity.
Immunization History
The patient received immunizations from the local health center as follows: 1
BCG, 3 Penta Hib, 3 OPV/IPV with no noted adverse reactions.
Personal and Social History

The patient lives with his parents and 2 siblings in a 1-storey house of mixed
materials, described to be well-lit and well-ventilated. With regular collection of
garbage. No noted smoking exposure and there were no pets in the household.
There were mosquitoes and flies at home as well as centipedes just outside their
area.
2
Past Medical History
There is no history of previous admissions nor surgery. There are also no
known allergy to food and medications.
Family Medical History

The patient is the first child of his mother, and the third child of his father. He
has 1 step brother and 1 step sister, ages 9 and 8, respectively. There is no family
history of malignancies, asthma, allergies, hypertension and diabetes. There is also
no history of the same mass/lesion in the family.
31 22
9 8 3
Physical Examination
General Survey: Awake, active, not in cardiorespiratory distress
Anthropometrics: Weight: 13 kg (z=0) Height: 89 cm (z=0)

Weight for height (z=0)
Vital Signs: BP: 90/60mmHg HR: 104 bpm Respiratory rate: 24 cpm
Temperature: 37.1 SO2: 98% at room air
Skin: With noted 1-2cm round, erythematous plaque on tight nipple area, no
necrotic tissue seen, no jaundice, no pallor, good skin turgor
HEENT: Anicteric sclerae, pink palpebral conjunctivae, non-sunken eyes, no

eye discharge, no alar flaring, septum midline, no nasal discharge,
moist lips and mucosa, normal set ears, no ear discharge
Respiratory: Symmetric chest expansion, no chest deformities, no retractions,

resonant on percussion, clear breath sounds
3
CVS: Adynamic precordium, no precordial bulge, PMI at the 4 th ICS LMCL,
normal rate regular rhythm, no lifts or thrills, no murmurs
Abdomen: Globular, normoactive bowel sounds, no bruits heard, tympanitic, soft,

no organomegaly, no masses palpated
Genitalia: Grossly male external genitalia, no discharge
Extremities: Grossly normal extremities, no edema, full and equal pulses capillary
refill time less than 2 seconds
Neurologic: Awake and alert, responsive to stimuli

CN I: not assessed
CN II: pupils 2-3mm equally and briskly reactive to light
CN III, IV, VI: full extraocular muscle movements on observation
CN V: good suck, good masseter tone
CN VII: no facial asymmetry
CN VIII: turns to sound
CN IX, X: good gag, midline uvula
CN XI: turns head equally
CNXII: tongue midline
Motor: good tone, no atrophy, moves all extremities symmetrically and
spontaneously
Sensory: responsive to light touch, pressure and pain on all extremities
DTRs 2+ on all extremities, (-) Babinski
No nuchal rigidity
Initial Impression
Centipede bite rule out envenomation
No stunting, no wasting
Course in the Ward

The patient was admitted due to the possibility of envenomation. Upon
admission, the patient was awake, comfortable at room air, with no signs of
respiratory distress. Heplock was inserted and laboratories were requested:
complete blood count with platelet count, prothrombin time, thrombin time, serum
electrolytes, venous blood gas, alanine transferase, total creatinine kinase, creatine
kinase myoglobin, blood urea nitrogen, serum creatinine and a 12 lead
Electrocardiogram. Diphenhydramine IV and tetanus toxoid were given. Cold
compress was also applied on the affected area. Patient was referred to the
toxicology section of another institution, advised to admit the patient and observe for
24 hours to rule out possibility of envenomation. They agreed with the laboratories
requested.
4
On the 2nd hospital day, there was noted improvement on the erythematous
plaque on the patient, with no noted fever, chest pain nor tachycardia. Laboratories
were noted to be unremarkable. The patient was then cleared for discharge.
Final Diagnosis
Centipede bite
No stunting, no wasting
APPENDIX
Laboratories
CBC 12/28/2019 VBG 12/28/2019

Hgb 123 g/L pH 7.30
Hct 38 pCO2 37 mmHg
WBC 16.3 x 109/L pO2 46 mmHg
Segmenters 65 HCO3 18.2 mmol/L
Lymphocyte 27 TCO2 19.30 mmol/L
s BEb -7.6 mmol/L
Platelet 487 x 109/L BEecf -8.20 mmol/L
Count SBC 18.50 mmol/L
SO2 76%
12/28/2019
ALT 12 U/L
AST 36 U/L
12/28/2019 CKMB 27 U/L
PT 13.6 seconds CK Total 144 U/L
ECG
INR 1.02 BUN 4.4 mmol/L (12/28/2019)
PTT 28.4 seconds Crea 32 umol/L Sinus
tachycardia
Na 136 mmol/L
K 4.1 mmol/L
Cl 102 mmol/L
Ca 2.48 mmol/L
Mg 0.80 mmol/L

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PHILIPPINE CHILDREN’S MEDICAL CENTER

Quezon Avenue, Quezon City

PRESENTER: CONSULTANT IN CHARGE:

MODERATOR: RESIDENTS IN CHARGE:

Informant and Reliability: mother; good reliability

Chief Complaint: centipede bite

History of Present Illness:

Birth and Maternal History

Personal and Social History

Family Medical History

General Survey: Awake, active, not in cardiorespiratory distress

Anthropometrics: Weight: 13 kg (z=0) Height: 89 cm (z=0)

HEENT: Anicteric sclerae, pink palpebral conjunctivae, non-sunken eyes, no

Respiratory: Symmetric chest expansion, no chest deformities, no retractions,

Abdomen: Globular, normoactive bowel sounds, no bruits heard, tympanitic, soft,

Genitalia: Grossly male external genitalia, no discharge

Neurologic: Awake and alert, responsive to stimuli

Course in the Ward

CBC 12/28/2019 VBG 12/28/2019

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