Transcript Case Management

Case Management
Case
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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:
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(+) 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
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(-) 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
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WBC: 8.8
Hgb: 114
Hct: 0.333
Plt: 169
Neut: 0.58
Lymph: 0.37
Baso: 0.57
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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
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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
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Liveraid
B Comp
TMPSMX
Para
(+) maculopapular rashes, trunk then becoming
generalized
Jan
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Present Working Impression
• ADR to TMP-SMX
• t/c CLD prob 2o to
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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
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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: 0.070.20
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
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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
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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
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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