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• 2 x 2 cm solitary plaque on the L

forearm; erythematous, smooth, raised border; tender, warm, firm to touch

• 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

3 weeks PTA

2 weeks PTA

History of Present Illness• 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

9 days PTA

History of Present Illness• 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.

7 days PTA

3 days PTA

History of Present Illness• Undocumented fever (patient

was warm to touch)• Ibuprofen (Dolan FP)

100mg/5mL suspension 3 mL every 4 hours was given

• Persistence of symptoms

1 day PTA

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 HistoryFeeding 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 RecallCHO CHON Fats Total Calories

Breakfast Oatmeal (1/2 cup) 11.5 1 61LunchMilk biscuit (2 pcs.) 23 2 100MeriendaKalamansi juice (4oz.)Ice cream (1/3 cup)

1023

2 40100

DinnerMilk (9 bottles – 8oz. each)

84 56 70 1190

ACI 1490RENI 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:

• 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

MemberAge Relationship Ed. Attainment Occupation Health

StatusCR 55 Father College graduate –

AB HistoryGovernment

employeehealthy

IR 30 Mother College undergrad Housewife healthy

AR 10 Sister Grade 4 Student healthy

ER 9 Brother Grade 3 Student healthy

RR 46 Uncle High School graduate

Unemployed healthy

Personal, Socioeconomic and Environmental History

• 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 ExaminationGeneral: Alert, awake, irritable, not in cardiorespiratory

distress, well-nourished, well-hydratedVital 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 solesHead: No gross head deformities, HC = 53 cm (z-score: +3), no

lesions on the head, equally distributed fine black hair, closed fontanels

Physical ExaminationPink palpebral conjunctivae, pupils 2-3 mm ERTL, anicteric scleraeNo 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 lightCN3, 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 11- symmetry 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 well-defined 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

• Glanders abscess • Histoplasmosis, African • Milkers nodules• Mycobacterium

marinum/granuloma skin • Skin infections/Pyoderma • Toxoplasmosis, congental • Whipples disease • Chromoblastomycosis/

chromomycosis • Farcy/Cutaneous Glanders • Cutaneous fungal infection

Infected organ, Abscesses

• Adenitis/lymph node • Furunculosis • Abscess, subcutaneous • Carbuncle • Pyoderma granuloma (vegetans)