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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 – 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, Nonasthmatic 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 icteresia and 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 Momethasone furoate, 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 Course at the ER Date PE Assessment 1/4/12 DEMS 110/60, 92, 24, 37.9 CAP, MR (+) congested sclerae, SJS 2o to PC, (-) NVE/CLAD Cotrimoxazole (+) lip desquamation ECE, (+) crackles R midbasal LF AP, DHS, NRRR, (-) murmurs Abdomen flat, soft, nontender FEP, PNB, (-) edema Plan Dxtics: CBC, Electrolytes (Na, K, Cl, Ca, P, Mg), Crea, Albumin, ALT, AST, UA, Blood GS/CS x 2 Blood Typing Txts: Diphenhydramine 50 mg IV Ceftriaxone 2 g IV Azithromycin 500 mg/tab Pacetamol 300 mg IV PRN for T> 38.50 • 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 ↑ Course at the ER Date Findings Assessment Plan 1/4/12 POD Seen drowsy, not in distress, moves all extremities BP 110/60, HR 104, RR 18, Temp. 36.2 Dirty icteric sclerae, hyperemic palpebral conjunctivae, (+) lip desquamation, (-) oral ulcer, (+) crackles on right mid LF, (+) generalized maculopapular rashes slightly with pustules, (+) jaundice CAP-MR Adverse Drug Event to TMP-SMX t/c Stevens Johnsons Syndrome 2o to TMPSMX Jaundice prob. 2o to viral hepatitis t/c Anemia of Chronic disease t/c UTI Ceftriaxone 2 g IV OD Azithromycin 500 mg/tab 1 tab OD Paracetamol 500 mg/tab 1 tab q4 for fever > 38 oC Momethasone fucoate ? 0.1%, apply once a day on affected surface Leveciterizine + Montelukast 5/con ? 1 tab OD Hydroxyzine 10 mg/tab 1 tab ODHS Course at the ER Date Findings Assessment ADR prob. 2o to TMPSMX (+) lip fissures and crusting SJS unlikely at this (+) multiple generalized time (must fullfill erythematous and slightly criteria of at least 2 coalescing to pustules mucosal sites) (+) slightly globular T/c drug abdomen hypersensitivity (+) RUQ tenderness syndrome Intact Traube’s space 1/4/12 (+) icteric sclerae DERMA (+) eye redness Plan Ceftriaxone 2 g IV OD Azithromycin 500 mg/tab 1 tab OD Paracetamol 500 mg/tab 1 tab q4 for fever > 38 oC Momethasone fucoate ? 0.1%, apply once a day on affected surface Leveciterizine + Montelukast 5/con ? 1 tab OD Hydroxyzine 10 mg/tab 1 tab ODHS Wet lips with pNSS Start Hyddrocortisone 100 mg IV q8 Emollients ad libido Course at the ER Date Findings 1/4/12 arousable, oriented ALLERGY (+) hyperemic conju/(+) conjunctival suffusion (-) matting eyelids, (+) icteresia (+) dry, crusty lips, (+) ronchi on BLLF, (+) crackles right base (+) tenderness at periumbilical to hypogastric area (+) generalized erythematous maculopapular rashes coalescing into plaques wiuth dry desquamation, (-) bullae, blisters Assessment Plan ADR to Cotri CONTINUE SJS less likely atthis time PREVIOUS t/c CAP MEDICATIONS t/c UTI t/c CLD sec to ALD r/o chronic hepatitis t/c cholestatic jaundice, r/o drug induced hepatitis r/o Hepatic encepth I Anemia from Chronic Disease AKI from poor intake Course at the ER Date Findings Assessment Plan 1/4/12 GEN MED 6 120/70, 102, 20, afebrile (+) conj. Hyperemia, (+) jaundice (+) erosions and hyperpigmented vermilion bullaes Globular abdomen, (+) direct epigastric and hypogastric tenderness, (+) generalized hyperpigmented round lesions, some confluent with associated scaling and erosions (-) discharge (-) blisters ADR prob. sec to TMPCONTINUE PREVIOUS SMX; SJS less likely MEDICATIONS t/c CLD sec to ALD, r/o Chronic Hep B infection AKI sec to renal hypoperfusion from poor intake on top of probable CKD t/c UTI Presently, not highly considering pneumonia Drug Oct Nov Dec 24 25 26 27 28 29 30 31 Liveraid B Comp TMPSMX Para (+) maculopapular rashes, trunk then becoming generalized Jan 1 = Present Working Impression • ADR to TMP-SMX • t/c CLD prob 2o to 1. 2. 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 Momethasone furoate 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 Course at the Wards Date Findings Assessment Plan 1/5/12 Still with pruritus ALLERGY Still with difficulty Maintained CONTINUE PREVIOUS MEDICATIONS sleeping and swallowing (-) fever (-) abd. Pain (+)↓ UO, tea colored urine ≈ 300 cc (+) ronchi B LF Date Findings Assessment 1/5/12 GEN MED 6 (+) with flank pain (+) decrease urine output (+) tea colored urine 90/60, 70, 20, 37oC (+) dry, cracked vermillion border of lips with areas of hyperpigmentations, (+) apthous ulcers (+) crackles Globular abdomen, nontender, non-palpable liver edge Maintained Plan CONTINUE PREVIOUS MEDICATIONS However upon Txt: Give hydrocortisone consultation with 250 mg IV q6H x 48 hours Allergy senior resident then taper and referral to Ranitidine 50 mg IVq 8o consultant: Dx: Stevens Johnson Syndrome with Nephritis Due to: 1. Involvement of buccal mucosa 2. Probable Interstitial nephritis Course at the Wards Date Findings Assessment/Lab Results Plan 1/5/12 WAPOD Referred for bloody NGT aspirate, ~ 80 cc fresh blood, (-) melena, (-) dyspnea, (-) dec. sensorium 100/70 88 20 99% Gastric Ulceration/BPUD vs. BEV Omeprazole drip 40 mg in 100 cc pNSS Cold saline lavage WBC: 19.7 6.9 Hgb: 92 105 Hct: 0.24 0.298 Plt: 45 69 Neut: 0.80 0.56 Lymph: 0.070.20 Mono: 0.12 0.04 Transfuse 6 units platelet concentrate Transfuse 1 unit pRBC PTXM x 4-6 Standby 1-2 u pRBC BUN: 28.10 26.7 Crea: 476 375 BCR: 14.58 CrCl: 12.55 Course at the Wards Date Findings Assessment Plan 1/6/12 RENAL I: 1300 O: 450 Restless, lethargic, afebrile, Blood tinged output per NGT ECE, tachypneic, (+) crackles Tachycardic (+) muddy brown urine Azotemia prob. from AKI prob. from Acute Tubular Necrosis cannot rule out acute nephritis Associated Renal hypoperfusion from 1. Systemic inflammatory state with febrile episodes 2. Recent UGIB and acute blood loss CONTINUE PREVIOUS MEDICATIONS ABG Repeat UA, may do urine eosinophil Suggest Sepsis work-up: blood GS/CS, Urine GS/CS Course at the Wards Date Findings Assessment Plan 1/6/12 GEN MED 6 I: 1360 O: 450 (+) UGIB, fresh blood/NGT = 500 cc Still with decrease urine output Still with decrease sensorium BM x 2 since yesterday Encephalopathy, Considerations: Hepatic from CLD Uremic prob. sec to AKI sec to Allergic interstitial disease Septic UGIB prob sec : Uremic gastritis BEV from portal hpn sec to CLD Steroid-induced gastritis GI mucosal involvement from SJS ADR to TMP-SMX t/c Complicated UTI Shift Hydrocortisone to Pip-Tazo 2.75 g Iv Hold Hydrocortisone for now Discontinue Ranitidine Course at the Wards Date Findings Assessment 1/6/12 ANES Referred for Intubation Pre-Intubation: 80/60, tachycardic ET tube size 8.0 inserted at level 19 Secretions suctioned O2 sats post intubation: 97% HR: 95 70/50 Maintained Plan Course at the Wards Date Findings Assessment Plan 1/6/12 GEN MED 6 GI (+) persistent decrease in sensorium (+) fresh blood/NGT (+) melena/diaper t/c Acute Fulminant Hepatitis prob. drug induced Start Somatostan 3 g in D5W 250 cc X 12 RTC For BT Ideally, for liver transplant For possible EGD and RBL once stabilized Abd. UTZ: (+) cirrhotic liver, (+) splenomegaly, (+) renal parenchymal disease, (+) contracted gallbladder Conferred with Derma: Provisional Biopsy Result: Vacuolar intergface dermatitis, drug reaction may be considered Facilitate BT Start dopamine, if still hypotensive start noradrenaline Course at the Wards Date Findings Assessment 1/6/12 GEN MED 6 Drowsy, intubated withdraws to pain BP 140/80 on Dopa at 12 mcg/hr HR 76 20 CAB, O2 sat 99% Acute fulminant hepatitis prob. drug induced (Co-trimoxazole) on top of CLD prob sec to 1. ALD, 2. PNC sec to Chronic Hepatitis, in hepatorenal syndrome Type II Shock prob. sec to 1. Hypovolemic sec to blood loss 2. Septic from urosepsis Encephalopathy 1. Hepatic St. 3-4, 2. Septic UGIB prob. sec to 1. BEV, 2. BPUD, 3. SRMI, 4. Steroid induced CLD prob. sec to 1. ALD, 2. FNC sec to Chronic Hep B Complicated UTI ADR to Cotri-moxazole 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 esophageal varices from CLD, 2. Bleeding peptic ulcer disease, 3. Stress related mucosal injury Problem List 1. 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