Transcript History of Present Illness

PHARMACOLOGY CONFERENCE
Andal, Ang, J, Ang JM, Ang, K.,
Aningalan, A.
General Data
• C.R.
• 1 y/o
• Male
Chief Complaint:
Swelling of the L arm
History of Present Illness
3 weeks PTA
• 2 x 2 cm solitary plaque on the L
forearm; erythematous, smooth,
raised border; tender, warm, firm to
touch
2 weeks PTA
• Lesion increased in size: 4x 4cm
• consult at a local clinic
– Prescribed to take Cloxacillin (unrecalled
dose), 3mL every 6 hours for 7 days
• The lesion decreased in size to about
3 x 3cm, soft to touch
History of Present Illness
9 days PTA
• Lesion became a 3x3cm fluctuant
abscess, tender, well defined border
• Consult at another local clinic
– I & D: discharge was noted to be bloody
and with pus, approximately 10 mL
– Clindamycin was discontinued, and was
prescribed Co-amoxiclav (Augmentin)
(unrecalled dose) 5mL every 8 hours
• Mother did not give the said
medication because she believed that
the incision and drainage was enough
to heal the lesion
History of Present Illness
7 days PTA
3 days PTA
• 4 x 4 cm plaque of the same character
appeared adjacent to the previous lesion.
• lesion evolved into an 4x4 cm abscess,
with erythmatous, well-defined margin,
tender to touch
• Co-amoxiclav(unrecalled dose) 5 mL every
8 hours was given
– noted appearance of maculopapular
rashes on the neck, back, abdomen
and legs so the medication
– discontinued after 2 days.
History of Present Illness
1 day PTA
• Undocumented fever (patient
was warm to touch)
• Ibuprofen (Dolan FP)
100mg/5mL suspension 3 mL
every 4 hours was given
• Persistence of symptoms
ADMISSION
Review of Systems
(-) wt loss, anorexia, weakness,
(-) blurring of vision, eye redness, eye itchiness, Iacrimation
(-) deafness, tinnitus, aural discharge
(-) anosmia, epistaxis, sinusitis, nasal discharge
(-) bleeding gums, oral sores, tonsillitis
(-) neck mass, neck stiffness, limitation of motion
(-) breast masses, discharge, trauma
Review of Systems
(-) dyspnea, alar flaring, cough, hemoptysis
(-) easy fatigability, chest pain,edema
(-) phlebitis, varicosities, claudication
(-) dyshpagia, nausea, vomiting, hematemesis,
melena, hematochezia, diarrhea, constipation
(-) urinary frequency, urgency, hesitancy,
dysuria, hematuria, nocturia
(-) joint stiffness, joint pain, muscle pain, cramps
Review of Systems
(-) heat-cold intolerance, polydipsia, polyphagia,
polyuria
(-) headache, speech disturbance, seizures
(-) anxiety, depression, confusion
Personal History
Gestational History, Birth and Neonatal
History
• born to a 29-year old, G3P2, housewife, living with a
54-year old government employee.
• regular prenatal check-up
• took Folic Acid and FeSO4
• 2 shots of Tetanus toxoid.
• no illicit drug use, alcoholic intake, exposure to viral
exanthems, teratogenic drugs, cigarette smoke and
radiation.
Personal History
• Gestational History, Birth and Neonatal
History
• No illnesses during the pregnancy
• Patient was born live, term, singleton, male,
via CS secondary to cephalopelvic
disproportion in Jose Reyes MM
• unrecalled birth weight and birth length.
• good cry at delivery, spontaneous respiration,
and not meconium-stained.
Personal History
Feeding History
• exclusively breast fed during the first 3 months and
was then shifted to Bonna milk
• shifted to Bonamil at 6 months and then to Nido
fortified at 1 year
• Complementary food was introduced at 6 months,
starting with mashed fruits and vegetables
• Currently takes Nido fortified; 1:1 dilution, 8-9
feedings/day, 7 oz/feeding
• Patient is not a picky eater; usually eats fruits,
vegetables, chicken liver, fish and rice
24-Hour Food Recall
Breakfast
Oatmeal (1/2 cup)
Lunch
Milk biscuit (2 pcs.)
Merienda
Kalamansi juice (4oz.)
Ice cream (1/3 cup)
Dinner
Milk (9 bottles – 8oz.
each)
ACI
CHO
CHON
Fats
11.5
1
61
23
2
100
10
23
2
40
100
84
56
70
Total Calories
1190
1490
RENI
1070
% Intake
139 %
Developmental History:
Patient is at par with age
 Walks alone with one hand held
 Stands alone
 Begins to feed with fingers
 Kisses on request
 Releases object on request
 Obeys commands with gestures
Past Medical History:
• No previous hospitalizations/major illnesses
• No previous surgeries
• No previous blood transfusions
Immunizations:
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incomplete immunization; unrecalled dates
BCG1
DPT123
OPV123
HepB 123
Measles
HiB1
Family History:
• (+) Diabetes Mellitus – maternal great
grandmother, maternal aunt
• (+) Hypertension – maternal grandmother
• (+) asthma – maternal grandfather
• (-) PTB, Cancer, Hematologic diseases, Goiter
Family Profile
Family
Member
Age
Relationship
Ed. Attainment
Occupation
Health
Status
CR
55
Father
30
Mother
Government
employee
Housewife
healthy
IR
College graduate –
AB History
College undergrad
AR
10
Sister
Grade 4
Student
healthy
ER
9
Brother
Grade 3
Student
healthy
RR
46
Uncle
High School
graduate
Unemployed
healthy
healthy
Personal, Socioeconomic and
Environmental History
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lives with her parents, 2 siblings and uncle
well-spaced, well-ventilated and well-lit
two-storey house made of cement
Drinking water is mineral water
Garbage is burned every day
Does not live near a factory and has no
pets.
• Exposed to cigarette smoke (Uncle)
Physical Examination
General: Alert, awake, irritable, not in cardiorespiratory
distress, well-nourished, well-hydrated
Vital Signs: CR:105 bpm, regular RR:25 cpm, regular T:36.5°C
Ht: 78 cm (z-score: 0, normal), Wt: 14 kg (z-score: 3, obese),
BMI= 23.3 (z-score: above 3, obese)
Skin: Warm, moist skin, (+) maculopapular rash on bilateral
thigh, palms and soles
Head: No gross head deformities, HC = 53 cm (z-score: +3),
no lesions on the head, equally distributed fine black hair,
closed fontanels
Physical Examination
Pink palpebral conjunctivae, pupils 2-3 mm ERTL, anicteric
sclerae
No tragal tenderness, no ear discharge, non-hyperemic
external auditory canal, intact tympanic membrane, with
retained cerumen
Midline septum, no nasal discharge, turbinates not
congested, no alar flaring
Moist buccal mucosa, no oral ulcers, nonhyperemic
posterior pharyngeal wall, tosils not enlarged
Supple neck, no palpable cervical lymph nodes, no masses,
thyroid gland not enlarged
Physical Examination
Heart: Adynamic precordium, AB at 4th LICS MCL, S1>S2
at apex, S2>S1 at base, no heaves, no lifts, no thrills,
no murmurs
Lungs: Symmetrical chest expansion, no retractions, no
use of accessory muscles, clear breath sounds
Abdomen: Globular, soft, with normoactive bowel
sounds, no tenderness, no masses
External Genitalia: Grossly male genitalia
Physical Examination
Extremities: No limitations in range of motion,
no joint swelling or tenderness; pulses full and
equal, no cyanosis, no clubbing, (+) warm,
tender, erythematous, fluctuant, 4x4cm mass
on the left forearm with well-defined border.
Neurologic Exam on Admission
• Alert, awake, aware of surroundings
• No asymmetry, no gross deformities, no bulging of fontanels,
no hydrocephalus
• Spontaneous muscle movements, no involuntary movements,
no tremors
• Cranial Nerves: CN2- visual tracking, blinks with bright light
CN3, 4, 6- no ptosis, pupils 2-3 mm ERTL; CN5- blinks upon gentle
air blowing; CN7- no facial asymmetry; CN8- turns head to
stimulus; CN9, 10- normal suck and swallowing; CN 11symmetry of SCM muscle bulk
• (-) Involuntary movements
• (-) Nuchal rigidity, (-) Babinski
Salient Features
• 1 y/o M
• (+) warm, tender, erythematous, fluctuant,
4x4cm mass on the left forearm with welldefined border
• (+) maculopapular rash on bilateral thigh,
palms and soles
• Irritable
• Undocumented fever
Symptom, signs and laboratory finding found in
the least number of disease
• Fluctuant Mass
Differential Diagnosis
• V—Vascular conditions of the skin like postphlebitic ulcers that cause a
discharge
• I—Inflammatory conditions of a noninfectious nature like erythema
multiforme, pyoderma gangrenosum, and pemphigus that produce
weeping. Specific infections are listed above.
• T—Traumatic conditions such as third-degree burns
• A—Autoimmune and allergic disorders associated with weeping vesicles
and ulcers, such as periarteritis nodosa and contact dermatitis
• M—Malformations such as bronchial clefts and urachal sinus tracts
• I—Intoxicating lesions such as a vesicular or bullous drug eruption
• N—Neoplasms such as basal cell carcinoma and mycosis fungoides that
produce weeping ulcers
Infectious Disorders
(Specific Agent)
• Immune deficiency, acquired
(AIDS/HIV)
• Infestations/fleas/mites/lice
• Sporotrichosis
• Cryptococcosis
• Glanders (malleomyces mallei)
• Loiasis/Loa loa infestation
• American
leishmaniasis/cutaneous
• Angiomatosis, bacterial
Bartonellosis
• Blastomycosis
• Cytomegalic virus, congenital
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Glanders abscess
Histoplasmosis, African
Milkers nodules
Mycobacterium
marinum/granuloma skin
Skin infections/Pyoderma
Toxoplasmosis, congental
Whipples disease
Chromoblastomycosis/chromo
mycosis
Farcy/Cutaneous Glanders
Cutaneous fungal infection
Infected organ, Abscesses
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Adenitis/lymph node
Furunculosis
Abscess, subcutaneous
Carbuncle
Pyoderma granuloma (vegetans)