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Case Management

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 Management

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  1. Case Management

  2. Case • M.R. • 59/M • Married • Roman Catholic • From Cavite • Unemployed

  3. Chief Complaint Fever

  4. 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

  5. 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

  6. 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

  7. 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

  8. 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

  9. 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

  10. 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

  11. Family Medical History • (-) DM, HPN, BA, PTB, Cancer, Kidney, liver and heart diseases • Allergies  

  12. Personal and Social • 40 pack year smoker • Moderate alcoholic beverage drinker, 3-4x/wk • Denies illicit drug use

  13. Course at the ER

  14. 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 ↑

  15. Course at the ER

  16. Course at the ER

  17. Course at the ER

  18. Course at the ER

  19. 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

  20. 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

  21. Course at the Wards

  22. Course at the Wards

  23. Course at the Wards

  24. Course at the Wards

  25. Course at the Wards

  26. Course at the Wards

  27. Course at the Wards

  28. 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

  29. 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

  30. 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

  31. 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 

  32. 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.

  33. 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)

  34. Stevens-Johnson Syndrome • Stopping medication causes • Supportive care • Fluid replacement and nutrition • Wound care • Eye care • Immunoglobulin intravenous (IVIG • Skin grafting

  35. Stevens-Johnson Syndrome • Medications • Pain meds • Antihistamines : itching • Antibiotics , when needed • Topical steroids to reduce skin inflammation • Intravenous corticosteroids  for adults

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