Formal Case Presentation

Formal Case PresentationPHCL 413: Pharmacy Practice Lab 3Jane SmithPharmD StudentCollege of pharmacy-King Saud University October 2011MM, a 68-year-old male visiting the primary care clinic

Chief ComplaintI have a rash all over my body which looks like measles and is very itchy. I also have a fever and my body aches like I have the flu.

History of Present IllnessFever, arthralgias, and a total body rash consisting of itchy, red, slightly raised papules; pain rated as 5 out of 10

MM was diagnosed with gout 6 months. he experienced 3 gouty attacks since then each treated with indomethacin History of Present Illnessmost recent gouty attack occurred 8 weeks ago and was treated with indomethacinMM started on Zyloprim approximately 7 weeks ago for the prevention of gouty attackspain score reported 2 weeks ago at PMD visit was 1 out of 10MM is on HCTZ for HTN

Medical HistoryGout (x 6 months)Hypertension (x5 years)

Surgical History None

Family HistoryMother died at age 75 with stroke; father alive at 92 with type 2 diabetes, hypertension, coronary artery disease (CAD) and gout

Social History MM is a single, retired postal worker. lives with his sister, nonsmoker, admits to alcohol use (45 beers per night) and frequent intake of junk food.

Medications ListDrug regimenIndicationCommentsAllopurinol(Zyloprim )300 mg po qdGoutStarted 7 weeks agoIndomethacin

50 mg PO TID at onset of gout attack for 2 days; 25 mg PO TID until resolution of attackGout6 monthsLisinopril 10 mg PO QD

HTNPatient discontinued on his own last week due to a cough(HCTZ)25 mg PO QDHTNStart date unknownHCTZ: Hydrochlorothiazide, HTN: hypertension Review of SystemsDenies any difficulty breathing, headache, nausea, vomiting, or pain associated with gout. Admits to achy muscles and joints, oral pain, and a sensation that his skin feels like ants are crawlingPhysical ExaminationGEN: Elderly male appearing older than his stated age; complaining of itchy rash and generalized painVS: BP 150/95, HR 80, RR 22, T 39C, Wt 75 kg, Ht 163 cm (BMI 28)HEENT: Ulcerations noted in the buccal mucosa and conjunctiva bilaterallyCOR: nl S1, nl S2, - MRGCHEST: Clear to A and PMention Possibly due to non-compliance and prolonged NSAID therapyA and P Auscultation and percussionMRG Murmur/rub/gallop11Physical ExaminationABD: WNLGU: No mucosal lesions notedRECT: DeferredEXT: Left great toe is slightly enlarged with minimal erythemaNEURO: A & O 3SKIN: Diffuse, symmetrical maculopapular rash on the abdomen, arms, and legs; urticarial plaques noted on the upper chest and neck

Macule: a flat skin lesion less than 1 cm in greatest diameter. When macules exceed 1 cm, the appropriate term is patch.Papule: a raised bump less than 1 cm in diameter. When papules exceed 1 cm in size, the appropriate term is plaque (palpable lesions elevated above the skin surface) or nodule (a larger, firm papule with a significant vertical dimension).Other morphological terms encountered in this clinical setting include:Pustule: a papule containing purulent fluid.Vesicle: a papule containing clear serous fluid.Bulla: a larger vesicle exceeding 1 cm.Urticaria: a wheal or hive.Hence, the term maculopapular rash implies a skin eruption of flat and raised lesions12Na 134 (134)Glu 6.1 (110)AST 2.5 (150)K 3.5 (3.5)Hgb 13 (13)ALT 3.3 (200)Cl 98 (98)Hct 0.35 (35)Alk phos 1.6 (95)HCO3 26 (26)Lkcs 12109 (12103)T bili 17.1 (1.0)BUN 15 (42)Plts 150109 (150103)Alb 40 (4.0)Scr 186 (2.1)Pertinent Laboratory Tests & DiagnosticsNot good slide Na 134 (135147 mEq/L)Glu 110(70110 mg/dL)AST 150(035 U/L)K 3.5 (3.55 mEq/L)Hgb 13 (1418 g/dL)ALT 200(035 U/L)Cl 98 (95105 mEq/L)Hct 35%(3949%)Alk phos 1.6 (0.52.0 kat/L)HCO3 26 (2228 mmol/L)Lkcs 12103 (3.29.8 103/mm3)T bili 1.0 (0.11 mg/dL)BUN 42(818 mg/dL)Plts 150103 (130400103/mm3)Alb 4 (46 g/dL)Scr 2.1(0.61.2 mg/dL)Calculated CrCls= 28.4ml/minNeed to mention the high values only, you dont need to read each value. Patient had slight hyponatremia (on HCTZ)LFTs are elevated possibly because of the DRESS syndrome, indicating possible systemic involvement BUN / Cr are elevated possibly because of the DRESS syndrome indicating possible systemic involvement Also pt is on NSAIDS 3 6 monthsHis WBC are elevated, because of DRESSHis hgb and hct are slightly lowBUN:Cr=20

Calculation of CrCls

IBWMales: IBW = 50 kg + 2.3 kg for each inch over 5 fee

Cockroft and GaultCrCl = (140 - age) x IBW / (Scr x 72)

DMRDGFR = 186(Creat/88.4)- 1.154(Age)- 0.203

14Pertinent Laboratory Tests & DiagnosticsLkc differential: 60% neutrophils (5462%), 20% lymphocytes (2533%), and 20% eosinophils (13% )Complement 4 (C4): 10 mg/dL (2050 mg/dL; 0.2 to 0.5 g/L)ESR 85 (020 mm/hr)Uric acid 6 (27 mg/dL)Antinuclear antibodies Blood, urine, and throat cultures 15Problem ListHypersensitivity reaction due to gout medicine Poorly controlled high blood pressureGout: seems controlledRenal insufficiency

16Drug Related ProblemsGout: ADR: hypersensitivity syndrome possibly due to his gout new medication (allopurinol)Hypertension Need additional therapy Renal insufficiency

Case WorkupProblem 1:Drug-Induced Adverse ReactionsProblem1: Hypersensitivity reaction due to allopurinolSubjective:I have a rash all over my body which looks like measles and is very itchy. I also have a fever and my body aches like I have the flu. Patient started allopurinol 7 weeks for gout

SummaryThe patient with an acute maculopapular rash presents a diagnostic challenge to the clinician. The term maculopapular is somewhat non-specific, as many eruptions will have a primary morphology of macules or papules, and the term may be mis-used to indicate any rash. The term rash is itself also non-specific and is sometimes incorrectly applied to any skin finding; eruption may be preferred for a cutaneous reaction of acute onset. However, the term maculopapular rash is in common clinical usage and will be retained here for purposes of simplicity. Synonyms for maculopapular rash include exanthematous eruption (exanthem) or morbilliform eruption.DefinitionsThe term maculopapular rash typically implies an acute and generalised eruption. A brief review of morphological terms is appropriate. Macule: a flat skin lesion less than 1 cm in greatest diameter. When macules exceed 1 cm, the appropriate term is patch.Papule: a raised bump less than 1 cm in diameter. When papules exceed 1 cm in size, the appropriate term is plaque (palpable lesions elevated above the skin surface) or nodule (a larger, firm papule with a significant vertical dimension).Other morphological terms encountered in this clinical setting include:Pustule: a papule containing purulent fluid.Vesicle: a papule containing clear serous fluid.Bulla: a larger vesicle exceeding 1 cm.Urticaria: a wheal or hive.Hence, the term maculopapular rash implies a skin eruption of flat and raised lesions. Morphology, duration and distributionInitial considerations in evaluating the maculopapular rash include the morphology, duration and distribution. Age, gender, family history, medicines, known allergies and exposures are also of primary importance.Lesions are typically erythematous or reddened, due to the presence of inflammation.Commonly, the eruption in a given patient will be a combination of macules, papules, patches, plaques and even other morphologies, though one morphology may predominate.Age may be the single most important predictive factor of diagnosis. In the absence of other data, maculopapular rash in adults is most likely to be drug-related, while maculopapular rash in children is most likely to be viral-related.The duration of the eruption may be acute (recent onset, less than 4 weeks), sub-acute (4 to 8 weeks) or chronic (more than 8 weeks). These timeframes are arbitrary.An acute eruption often has a specific trigger, such as an allergic (e.g., medicine) or infectious (e.g., viral) exposure. The distribution of the eruption can be localised or generalised.Other clinical factors, including the presence of fever, headache and other signs of illness are of great importance. Some conditions with a serious clinical course have a maculopapular eruption as a presenting sign and evaluation should be carried out urgently.Classification by aetiologyThe primary differential diagnoses to consider for a maculopapular rash are:Drug eruptionsViral exanthemsRickettsial infectionsBacterial infections (including those that are toxin-mediated)Systemic diseases (e.g., acute graft versus host disease and Kawasaki disease)Rheumatological diseases.Febrile illness and rashGenerally, a maculopapular eruption in the absence of fever or systemic systems is not urgent. When fever or signs of illness are present, urgent illness must be considered. A number of conditions with serious clinical course may have a maculopapular eruption as a component, and evaluation should be carried out urgently if suspected. Among them are:MeningococcaemiaAnaphylactic reactionsToxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS)Drug reaction with eosinophilia and systemic symptoms (DRESS)Staphylococcal scalded skin syndrome (SSSS) and toxic shock syndrome (TSS)Rickettsial spotted fever.20Objectives: Diffuse, symmetrical maculopapular rash urticarial plaques Systemic hypersensitivity involvementconjunctival and oral lesionselevated LFTfever of 39CProblem1: ADR Hypersensitivity reaction The presence of mucosal lesions in the mouth and conjunctiva is indicative of a severe systemic hypersensitivity reaction rather than an isolated skin reaction. Mucous membrane involvement of the lips, eyes, nasal cavity, and genitalia indicate progression of the rash to a systematic condition such as Stevens-Johnson syndrome. Other markers of a systemic reaction include elevations in liver tests and elevated renal indices.

21Objectives: leukocytosis with eosinophilialow complement 4 concentrationelevated ESRelevated BUN and SCr no evidence of infection or autoimmune markers

Problem1: ADR Hypersensitivity reaction drug rash with eosinophilia and systemic symptoms "DRESS caused by allopurinol potentially life-threatening patient need to be admittedProblem1: ADR Hypersensitivity reaction Assessment

Macular-papurla rash

drug rash with eosinophilia and systemic symptoms "DRESSDrug rash with eosinophilia and systemic symptoms "DRESSA triad of rash, eosinophilia and internal organ involvementDrugs: Allopurinol: does related, renal insufficiency risk factorAnticonvulsantssulfonamidesMortality: 10% due to systemic involvement of the liver, kidneys, or lungsCite your reference hereDrug rash with eosinophilia and systemic symptoms "DRESSManagementDiscontinue causative agentthe skin rash resolves and laboratory abnormalities normalize over a period of 4 to 8 weeks. Supportive care: Systemic corticosteroids (0.51 mg/kg/day prednisone or steroid equivalent) based on the severity of organ involvementIV hydrationAntihistamine for pruritisOcular lubricants, mouth wash for local lesions Cite your reference herePlan: Goal of therapy:Prevent progression of the hypersensitivity reaction and limit the involvement of further organs damage. Discontinue allopurinol.Interview patient to assess for other cause of the reaction Problem1: ADR Hypersensitivity reaction Interview the patient for information regarding OTC, homeopathic, and other complementary drug therapies as potential causes of the adverse event.

28Supportive care: Oral antipyretics diphenhydramine 2550 mg PO q6h.Suggest ocular lubricant.hydrogen peroxide gargle, antiseptic mouthwash (chlorhexidine), and an anesthetic (benzocaine spray) for oral lesions.Suggest initiating high-dose steroids 1 mg/kg/day prednisone (or equivalent) to limit progression of hypersensitivity syndrome.Problem1: ADR Hypersensitivity reaction If other potential causes are ruled out, update patient's allergy history to include allopurinol-related hypersensitivity syndrome.Monitor rash, LFTs, and renal function for progression/resolution of the event

Problem1: ADR Hypersensitivity reaction S: none. Self discontinuation of lisinopril one week ago due to ADR (cough)

O: BP 150/95, HR 80, BMI 28 kg/m2

Problem2: Poorly controlled BPAssessmentPatient BP goal is