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Case Management. Case. M.R. 59/M Married Roman Catholic From Cavite Unemployed. Chief Complaint. Fever. Profile. Diagnosed with Liver disease in July 2011
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Case • M.R. • 59/M • Married • Roman Catholic • From Cavite • Unemployed
Chief Complaint Fever
Profile • Diagnosed with Liver disease in July 2011 • Presentation: bipedal edema , abdominal enlargement, and icteresia lost to ff-up until Sept. 2011 consult with private MD and given Silymarin and Vitamin B complex for the liver as maintenance meds • Non-diabetic, Non-hypertensive, Non-asthmatic and no known allergies to foods and drugs
History of Present Illness • 11 days PTA: (+) Fever 38-39oC with associated hypogastric tenderness private MD, UA done, A> UTI • Given: Cotrimoxazole 800/160 mg/tab 1 tab BID and Paracetamol 500 mg PRN for fever with temporary lyses of fever. • 7 days PTA: (+) developed maculopapular rashes initially on bilateral UE chest and trunk area; continued on Cotri, and still with on and off fever
History of Present Illness • 5 days PTA: skin lesions generalized • (+) pruritus and erythema with involvement of the face about the same time he developed deepening icteresiaand jaundice, (+) conjunctival suffusion, (+) dry skin beginning flaking of old lesions • Discontinued TMP-SMX as advised by a relative (-) blisters/bullae formation
History of Present Illness • 2 days PTA: • (+) development of lip crusting and cracking • (+) anorexia • (+) irritable with difficulty sleeping • (+) soft stools, non-melenic, non-bloody, non-mucoid, yellowish = 2-3 x/day • (+) cough, non-productive • Still with on and off fever • Still allegedly with good urine output but with tea colored urine • Consult with private MD advised referral to Derma
History of Present Illness • 1 day PTA: Consult at PGH-Derma • A> ADR sec. to Cotri, cannot fully commit to SJS/EM. Skin biopsy done and was given Momethasonefuroate, Montelukast, levociterizine, Hydroxyzine PRN -> sent home’ • Day of admission: • (+) fever (Tmax 40 oC)with chills • (+) generalized weakness • (+) drowsy ER Admission
Review of Systems • (-) headache (-) weight loss • (-) BOV (-) d/c (-) tinnitus (-) gum bleeding • (-) dyspnea (+) cough (-) sputum (-) hemoptysis • (-) chest pain (-) PND (-) 2 P orthopnea (-) claudication • (-) abdominal tenderness(-) diarrhea (-) constipation( (-) hematochezia • (+) dysuria (-) hematuria (-) proteinuria (-) oliguria • (-) polyphagia (-) polydipsia (-) polyuria (-) heat and cold intolerance • (-) edema(+) jaundice(-) ecchymosis (-) petechiae (-) hematoma
Past Medical History • (-) DM, HPN, PTB, BA, Cancer, Kidney, liver and heart diseases • Denies allergies • (-) Previous surgeries • Allegedly, had liver problem last July 2011 after presenting with jaundice Abd. UTZ done showing normal findings, AST and ALT done were also normal, started on Silymarin, and Vitamin B Complex
Family Medical History • (-) DM, HPN, BA, PTB, Cancer, Kidney, liver and heart diseases • Allergies
Personal and Social • 40 pack year smoker • Moderate alcoholic beverage drinker, 3-4x/wk • Denies illicit drug use
12/29/11 • WBC: 8.8 • Hgb: 114 • Hct: 0.333 • Plt: 169 • Neut: 0.58 • Lymph: 0.37 • Baso: 0.57 • BUN: 26.70 • Crea: 375 • BCR: 17.59 • CrCl • AST: 182 ↑ • ALT: 131 ↑ • Alb: 15 ↓ • Ca: 1.87 (2.37) • P: 1.62 ↑ • Mg 1.05 • Na 127 ↓ • K 4.5 • Cl 99 • WBc: 6.9 • Hgb: 105 • Hct: 0.298 • Plt: 69 • Neut: 0.56 • Lymph: 0.2 • Mono: 0.04 • Baso: 0.02 • Anisocytosis + • Macrocytosis • Poikilocytosis + • TB 296.2↑ • DB 157.1 ↑ • IB 139.1 ↑
Present Working Impression • ADR to TMP-SMX • t/c CLD prob 2o to • Chronic Hepa B infection • Alcoholic liver Disease • AKI from Renal Hypoperfusion from sepsis, poor oral intake, third spacing from hypoalbuminimea • UTI • Not highly considering CAP-MR - Patient is for admission
Medications on Board • Ceftriaxone 2 g IV OD • Hydroxyzine 10 mg/tab 1 tab ODHS • Montelukast + Levocetirizine 5/10 mg/tab OD • Momethasonefuroate 0.1% lotion apply on affected areas once day • Paracetamol 500 mg/tab 1 tab q4 prn for T>38oC • Petroleum jelly lotion ad libidum • Lactulose 30 cc TID to make 3-4 BM/day
Labs • PT: 14.0/90.8/0.10/8.74 • PTT: 30.6/>245 • UA: dark, yellow, cloudy, pH 5.5 SG 1.015, (-) CHON, CHO, RBC abundant, WBC 1-3, +2 bacteria, EC few, fine granular cast 0.3, bil +2, leukocyte trace, NO2 (-), Hgb + 3 • Urine GS (-) PMN, (-) organisms
1/6/12: 7:50 PM • Patient’s son signed DNR, to consume meds and no blood/ blood products to be given to the patient, and to stop all IV fluids of the patient • 10:58: WAPOD • Patient referred for BP=0, HR=O • Noted DNR status • ECG done: asystole • Time of death: 10.53 PM • PCOD: Hypovolemic shock sec to blood loss prob. from 1. Bleeding esophagealvarices from CLD, 2. Bleeding peptic ulcer disease, 3. Stress related mucosal injury
Problem List • Generalized body rash with fever • Considerations: ADR to TMP-SMX; SJS 2. Increasing abdominal girth, jaundice, increasing liver enzymes, hyperbilirubinemia • Chronic liver disease from Hep B infection • Hepatitis sec. to hypersensitivity reaction to TMP-SMX 3. Oliguria, tea colored urine, hyaline cast, increase BUN, increase creatinine • Dehydration from poor intake • Allergic interstitial nephritis 4. Bilateral pulmonary crackles • Infection? (pneumonia) • Acute pulmonary congestion from AKI
Stevens-Johnson Syndrome • Signs and Symptoms • Facial swelling • Tongue swelling • Hives • Skin pain • A red or purple skin rash that spreads within hours to days • Blisters on your skin and mucous membranes, especially in your mouth, nose and eyes • Shedding (sloughing) of your skin • If you have Stevens-Johnson syndrome, several days before the rash develops you may experience: • Fever, Sore throat, Cough, Burning eyes
Stevens-Johnson Syndrome • Exact cause can't always be identified. Usually, the condition is an allergic reaction in response to medication, infection or illness. • Medication causes: • Anti-gout medications, such as allopurinol • Nonsteroidal anti-inflammatory drugs (NSAIDs), often used to treat pain • Penicillins • Anticonvulsants • Infectious causes: • Herpes (herpes simplex or herpes zoster), Influenza, HIV, Diphtheria, Typhoid, Hepatitis • Physical stimuli, such as radiation therapy or ultraviolet light.
Stevens-Johnson Syndrome • Diagnosis is based on thorough medical history, physical exam and the disorder's distinctive signs and symptoms. • To confirm the diagnosis: skin (biopsy)
Stevens-Johnson Syndrome • Stopping medication causes • Supportive care • Fluid replacement and nutrition • Wound care • Eye care • Immunoglobulin intravenous (IVIG • Skin grafting
Stevens-Johnson Syndrome • Medications • Pain meds • Antihistamines : itching • Antibiotics , when needed • Topical steroids to reduce skin inflammation • Intravenous corticosteroids for adults