BP1 SGD1

TOPICS: (1) Wound Healing and repair; (2) hemodynamics, thrombosis and shock; (3) and
immune system and rheumatologic disorders.

Name: Stan, 18/M

CHIEF COMPLAINT: Weakness

SYMPTOMS
● Lethargic/Restless
● Fever + High Fever + Myalgia + Joint Pain
● Pale, Boggy Nasal Mucosa (Allergic Rhinitis [undiagnosed])
● Headache
● Suspected Hepatomegaly (3 cm below the RCM) + GI Pain (Epigastric RUQ)
● Macular, Erythematous Rashes (at the LE, UE and Trunk)
● Diarrhea + Dry Oral Mucosa + Hyperactive

VITAL SIGNS
● Temperature = 38.5 oC (ABOVE normal)
● HR = 128/min (ABOVE normal)
● RR = 28/min (ABOVE normal)
● BP = 70/50 mmHg (BELOW normal)

TIMELINE:

14 days before 8 days before Between Days 2 days before On the day of
ED (Day 0) ED (Day 6) 6-12 ED (Day 12) ED (Day 14)

Given amoxicillin High fever (39.7 Weak

He went to Developed fever but stopped after oC)
Coron Palawan two days of use Lethargic
Headache Myalgia
Stopped due to Restless
rash, diarrhea Joint Pains
and abdominal
pain Headache

Was given Increasing

Cetirizine for the Abdominal Pain
rashes
Loose, non-
 bloody stools

OTHER IMPORTANT INFORMATION (PAST HISTORY):

1. Last asthma attack is when he was 8 years old (10 years ago)
2. Known Allergies: Ibuprofen
a. Others: Amoxicillin [unsure]
3. Can tolerate medications: Paracetamol and Mefenamic Acid
4. Undiagnosed allergic rhinitis (Has recurrent symptoms of runny nose, sneezing, itchy
nose and post nasal drip, with no associated fever. This would usually occur in the
mornings, about 2-3x/week)
5. Athlete (Basketball Varsity)
6. No notable family history

RULED IN:

1. Dengue
2. Malaria

RULED OUT:

1. Chikungunya (dahil sa full motion)

2. Anaphylactic Shock (good air entry)
3. Traveler’s Diarrhea (just 6-48 hrs)

PROBLEM LIST:

1. Shock [Considering Hypovolemic]

2. Dehydration secondary to Diarrhea
3. Presence of Rashes
4. Allergic Rhinitis [Undiagnosed, Recurrent]
5. Hepatomegaly -- may be secondary to Dengue, ADR
6. Medical malpractice by giving ibuprofen (which he was allergic to)
7. Childhood Asthma [stable]

DRUGS: mechanisms of action, efficacy, safety and suitability.

1. Paracetamol (COX Inhibitor)

● AKA Acetaminophen
● A known Analgesic, Antipyretic (a central analgesic effect that is mediated through
activation of descending serotonergic pathways)
● A weak COX-1 and COX-2 inhibitor in peripheral tissues and possesses no significant
antiinflammatory effects.
● MOA:
○ Inhibition of prostaglandin (PG) synthesis or through an active metabolite
influencing cannabinoid receptors
○ Prostaglandin H2 synthetase (PGHS) is the enzyme responsible for metabolism
of arachidonic acid to the unstable PGH2.
■ PGHS comprises of two sites: a cyclooxygenase (COX) site and a
peroxidase (POX) site.
○ The conversion of arachidonic acid to PGG2 is dependent on a tyrosine‐ 385
radical at the COX site.
○ Formation of a ferryl protoporphyrin IX radical cation from the reducing agent
Fe3+ at the POX site is essential for conversion of tyrosine‐ 385 to its radical
form.
○ Paracetamol acts as a reducing cosubstrate on the POX site and lessens
availability of the ferryl protoporphyrin IX radical cation.

● Efficacy:
○
● Safety:
○ In therapeutic doses, a mild increase in hepatic enzymes may occasionally occur
in the absence of jaundice; this is reversible when the drug is withdrawn. With
larger doses, dizziness, excitement, and disorientation may occur.
○ DO NOT OVERDOSE
● Suitability:
 ○ Acute pain and fever may be effectively treated with 325–500 mg four times daily
and proportionately less for children. Dosing in adults is now recommended not
to exceed 4 g/d, in most cases.

2. Amoxicillin (B-Lactam)

● For Gram Positive organism infections

● MOA:
○ Absorption of orally administered
○ Penicillins, like all β-lactam antibiotics, inhibit bacterial growth by interfering with
the transpeptidation reaction of bacterial cell wall synthesis .
● Efficacy:
● Safety:
○ The penicillins are generally well tolerated, and unfortunately, this encourages
their misuse and inappropriate use.
○ Most of the serious adverse effects are due to hypersensitivity
● Suitability

3. Ibuprofen

● An NSAID used as a painkiller/analgesic and anti-inflammatory

● MOA:
○ Non selective COX inhibitor
○ The NSAIDs decrease the sensitivity of vessels to bradykinin and histamine,
affect lymphokine production from T lymphocytes, and reverse the vasodilation of
inflammation.
● Efficacy
● Safety (Contraindications)
○ The drug is relatively contraindicated in individuals with nasal polyps,
angioedema, and bronchospastic reactivity to aspirin.
○ Hypersensitivity (including asthma) to ibuprofen or other NSAIDs.
○ History of gastrointestinal bleeding, perforation, or ulceration related to NSAID
therapy.
○ Severe renal or hepatic impairment.
● Suitability

4. Mefenamic Acid

5. Cetirizine

● Anti-histamine
● MOA:
○ An antihistamine used to relieve allergy symptoms such as watery eyes, runny
nose, itching eyes/nose, sneezing, hives, and itching
 ○ A piperazine derivative and metabolite of hydroxyzine, is an antihistamine which
competitively and selectively inhibits H1 receptors in the gastrointestinal tract,
blood vessels, and respiratory tract
● Efficacy
● Safety
○
● Suitability

DIAGNOSTICS:

1. Dengue IgG/IgM (to see if dengue since he went to Coron, Palawan)

2. Blood Smear (to see for Plasmodium)
3. Rapid Diagnostic Test (RDT) - for malaria
4. Liver (SGPT/SGOT for the suspected hepatomegaly)
5. Fecalysis (for microbe culture of the feces because of diarrhea)
6. CBC (for the presence of infections, platelet count)

TREATMENT PLAN:

1. Intervention for the Allergic reaction to Ibuprofen

a. Antihistamine
2. Provide fluids & electrolytes to alleviate shock
a. IV Lactated Ringer’s Solution
b. Provide oral rehydrations salts (ORS)
3. Rehydrate to alleviate dehydration
4. Education Plan to answer the infection
a. Proper / Protective Wear
b. Safer Behavior
c. Avoid exposure, breeding areas, etc.
5. Treatment for Hepatomegaly depends on its underlying cause (ADR or Infection)
6. Discontinue and prevent any more usage of amoxicillin
a. Investigate if Px is really allergic to Amoxicillin, since his mother said that Px
tolerates Amoxicillin.
7. Allergic rhinitis Commented [1]: https://www.uptodate.com/contents/p
a. Pharmacotherapy: Glucocorticoid Nasal Spray harmacotherapy-of-allergic-
rhinitis?search=allergic%20rhinitis%20treatment&sourc
i. First-generation – Beclomethasone, flunisolide, triamcinolone, and e=search_result&selectedTitle=1~150&usage_type=de
budesonide (10 to 50 percent bioavailability) fault&display_rank=1
ii. Second-generation – Fluticasone propionate (<2 percent), mometasone
furoate (<0.1 percent), ciclesonide (<0.1 percent), and fluticasone furoate
(<1 percent)
b. Educate: Allergen avoidance, reduction of allergens.
c. Allergen Immunotherapy: Of note, subcutaneous immunotherapy helps prevent
the development of asthma in children with allergic rhinitis and thus should be
given special consideration in the pediatric population.
8. Talk to the Doctor about the Medical Malpractice, explore options
 a. Possible legal action
9. Revisit what is effective in keeping asthma stable

QUESTIONS
1. What is your problem list?
1. Allergic reaction to Ibuprofen
2. Shock [considering Hypovolemic]
3. Dehydration secondary to Diarrhea
4. Symptoms of Infection (i.e. Rashes, Fever, Weakness etc.)
5. Hepatomegaly -- may be secondary to Dengue, ADR
6. Adverse reaction to Amoxicillin
7. Allergic Rhinitis [Undiagnosed, Recurrent, explains the pale boggy nasal mucosa]
8. Medical malpractice by giving Ibuprofen (which he was allergic to)
9. Childhood Asthma [stable]
2. What is your assessment of each problem?
1. Allergic reaction to Ibuprofen
a. Angioedema caused by administration of Ibuprofen.
b. Px had an established allergy to Ibuprofen.
2. Shock [considering Hypovolemic]
a. Indicated by the elevated HR, RR, and decreased BP
b. Likely hypovolemic due to fluid loss from diarrhea
c. Unlikely septic as no exposure was noted, but may still be considered.
d. Unlikely cardiogenic as Stan has no Hx or known cardiac problems
e. Unlikely anaphylactic because of the clear airways
f. Urgent (needing immediate intervention)
3. Dehydration secondary to Diarrhea
a. Symptoms of dehydration are observed (dry oral mucosa)
b. Dehydration is closely related to diarrhea
4. Symptoms of Infection (i.e. Rashes, Fever, Weakness etc.)
a. Possible signs of infection: high fever, inflammatory response.
5. Hepatomegaly -- may be secondary to Dengue, ADR
a. Liver was palpable 3 cm below RCM. Accdg to journal references, palpable liver
more than 2 cm below the RCM may be considered hepatomegaly. Commented [2]: https://www.ncbi.nlm.nih.gov/pubmed
b. This may be related to some infections that are being considered: dengue, /8115880
malaria (need serologic testing to determine infection)
6. Adverse reaction to Amoxicillin
a. Developed abdominal pain, diarrhea and mildly pruritic rash
b. However, these symptoms may have a different origin as they did not subside in
spite of discontinuation.
7. Allergic Rhinitis [Undiagnosed, Recurrent, explains the pale boggy nasal mucosa]
a. Up to 2 to 3x per week in the mornings
b. Common findings of this are specifically ‘pale boggy nasal mucosa.’ Commented [3]: https://pedclerk.bsd.uchicago.edu/pa
8. Medical malpractice by giving Ibuprofen (which he was allergic to) ge/allergic-rhinitis
 a. In spite of History and established allergy / hypersensitivity to Ibuprofen,
physician prescribed it.
9. Childhood Asthma [stable]
a. Last asthma attack was 8 years ago.

1. Discuss the drugs given to Stan by giving their mechanisms of action, efficacy,safety
and suitability.

3. What is your diagnostic plan? And what is the rationale?

4. After getting the results of the laboratory tests, how will you update your problem list?
5. What is your therapeutic plan?
6. Make/create a slogan that succinctly expresses the essence of the disease/primary
diagnosis.