Patient Name: JH DOB: Allergies: Augmentin (itching)

Transcription

1 Patient Name: JH DOB: Allergies: Augmentin (itching) Case Presentation Jon Manocchio Mount Carmel Medical Center SUBJECTIVE: JH is a 36 yo AAF presenting with an exacerbation of hidratenitis suppurativa and persistent diarrhea HPI: exacerbation of hidratenitis suppurativa for approximately 3 days and diarrhea approximately 3 weeks (correlating with antibiotic use) that has recently resolved. JH has been admitted to the hospital for past exacerbations. PMH: DM, HTN, obesity, iron deficiency anemia, asthma, hidratenitis suppurativa, GERD, bipolar disorder FH: unavailable SH: denies tobacco and substance use Surgeries: C-Section Home Medications: Remicade (infliximab) 1275mg q6 weeks (increased from 875mg) Lopressor (metoprolol) 50mg po BID Prevacid (omeprazole) 30mg po daily Hospital Medications: Lopressor (metoprolol) 50mg po BID Prevacid (omeprazole) 30mg po daily Proventil (albuterol) one inh q4-6h PRN Lovenox (enoxaparin) 40mg SubQ daily Vancocin (vancomycin) 1g IV q12h (increased to 1.5g IV q12h) Zosyn (pipercillin/tazobactam) 3.375g q6h Tylenol (acetaminophen) 650mg q4h PRN fever/pain Tylenol #3 (acetaminophen 300mg/codeine 30mg) 1 po PRN Remicade (infliximab) 1275mg IV once Benadryl (diphenhydramine) 50mg PRN Remicade injection Solu-Medrol (methylprednisolone) 125mg IV PRN Remicade injection Dulcolax (bisacodyl) 10mg BID PRN Milk of Magnesia PRN

2 OBJECTIVE: Laboratory Data: March 10, 2011 Vitals: T 98.7 o F, Wt 179.3kg, HR 116bpm, R 20bpm, Pul Ox 99%, BP 142/68 (all remained stable) CBC: WBC 11.6, Hg 9, Hct 30.2, plt 409, RBC 4.01 BMP: Na 140, K 4.1, Cl 106, CO 2 25, BUN 5, scr 0.78, Glu 71 Others: Ca 8.6, Alb 3.2, Cor Ca 9.2, Phos 3.6 Coags: PT 10.2, INR 0.9, APTT 31 March 12, 2011 CBC: WBC 10.5, Hg 8.4, Hct 28.5, Plt 373, RBC 3.81 BMP: Na 142, K 4.2, Cl 104, CO2 27, BUN 6, scr 0.94, Glu 76 Others: Ca 8.8 Vanc Trough: 6.1 (15-20) Culture and Sensitivity: C-diff neg x 1 March 14, 2011 BMP: Na 140, K 4.7, Cl 104, CO2 27, BUN 8, scr 0.97, Glu 82 Others: Ca 9.0, Alb 3.1, Cor Ca 9.7, Phos 5.2 Vanc Trough: 11 (15-20) Physical Exam: Neck: supple Resp: CTA CV: RRR Breasts/Chest: lesions with purulent discharge Abd: neg guarding, nondistended Neuro: A/O x 3, C2-C12 intact PROBLEM LIST: Exacerbation of hidratenitis suppurativa Persistent Diarrhea HTN DM Asthma Iron Deficiency Anemia Obesity GERD Bipolar Disorder ASSESSMENTS AND PLANS: Exacerbation of hidratenitis suppurativa: JH manages her hidratenitis suppurativa (HS) through her dermatology office. Her history is significant for HS flares all over her body. She receives Remicade (infliximab) infusion every 6 weeks (1275mg). HS is a chronic skin inflammatory disease that presents with numerous blackheads and/or red and tender papules (lesions). Often times, these lesions enlarge and break open and produces a purulent discharge. While there is no specific cause noted, it is thought that, like adolescent acne, hair follicles become blocked with fluid, skin cells, or other particulates and block the sebaceous (oil) gland, which results in inflammation. The hair follicle can often become

3 infected, usually by gram pos streptococcus or staphylococcus, as these organisms are prolific on the skin surface. JH also displays numerous risk factors for developing HS including: AA, female, obesity, age between puberty and 40, among other possibilities (hormones, genetics, etc). Upon review of her last admittance, JH was inpatient for 4 days and treated with antibiotics. For this admittance, JH came in on Cleocin (clindamycin) for therapy. Goals for JH include: resolution of discharge from lesions, limiting exacerbation of HS, antibiotic therapy (based on WBC counts and risk), have JH follow-up with dermatologist. Since JH has failed clindamycin therapy, begin more aggressive antibiotic therapy. Vancomycin 1g q12h IV should be implemented for broad gram pos coverage (including MRSA) as well as Zosyn (pipercillin/tazobactam) 3.375g q6h IV for broad gram pos (streptococcus, enterococcus), gram neg (pseudomonas aeruginosa, enterobacter, serratia, Escherichia coli, etc), and some anaerobes. In order to manage the actual exacerbation of HS, her dermatologist was contacted about giving her a dose of Remicade (infliximab). It was agreed that JH should receive her infliximab 1275mg infusion (confirmed PPD test). In order to avoid anaphylactic reactions, JH was pre-medicated with Benadryl (diphenhydramine) 50mg and Solu-Medrol (methylprednisolone) 125mg. During the infliximab infusion, it is important to monitor vitals every 10 minutes (if abnormal) as well as LFT s (concern if >5x uln, though she has had no issues in the past. JH remained stable over the weekend, however, after the first vancomycin trough level came back at 6, the dose was increased to 1.5g q12h IV to avoid resistance and provide better therapy. A second trough level was drawn and returned as 11. A third trough level was ordered in another 3 days (if it returns subtherapeutic, consider increasing dose and continue monitoring and if it returns therapeutic, no additional changes are needed). Vancomycin toxicity should be monitored (ototoxicity, nephrotoxicity, skin rash, etc) though unlikely as other potentiating medications are not being utilized. JH was ready to be discharged on Monday afternoon. Since IV antibiotic therapy was not yet completed, it was decided to place a midline catheter so that JH could complete her IV course of antibiotics on the outpatient basis for an additional 7 days (Vancomycin 1.5g q12h IV and Rocephin (ceftriaxone) 2g q24h). Ceftriaxone will have a similar spectrum of coverage compared to Zosyn (except pseudomonas aeruginosa). Counsel JH to take Benadryl if itching is noted and to report adverse effect to PCP. JH was also given a prescription for Ultram (tramadol) 50mg q6h PRN pain (associated with exacerbation of HS). If exacerbations continue more frequently or become unmanageable, JH should consider surgical options. JH should follow-up with her PCP and/or dermatologist in 7-10 days. Persistent Diarrhea: JH presented to the hospital with a history of diarrhea for approximately 3 weeks (recently resolved). JH was on Cleocin (clindamycin) antibiotic therapy at this time. JH should be assessed for her hydration status, as dehydration can easily set in with persistent diarrhea. JH did not note any blood or other abnormalities with the diarrhea. Goals for JH include: confirm cause of diarrhea, monitor electrolyte levels (currently wnl) and hydration status. Since clindamycin is noted for causing C. diff infections, a test was immediately ordered to confirm or rule out infection. Upon review of the results (c. diff neg), no further treatment is needed. Since the diarrhea seemed to have resolved with conclusion of antibiotic use, it can be noted as an adverse event related to the medication. Since JH is starting a new course of antibiotics with current exacerbation of HS, counsel her on the importance of notifying PCP if diarrhea persists after 3 days, if she feels dizzy or light headed, if diarrhea appears to be bloody or excessively malodorous, and to replace fluids as often as possible (preferably a clear Gatorade since it has electrolytes). HTN: Upon admission, JH presented with slightly elevated systolic blood pressure (goal < 130/80 mmhg) as well as an elevated HR. Goals for JH include: reducing blood pressure to goal limit, counsel on

4 medication adherence regardless of symptomatology. Since JH is close to her goal, counsel JH on a low sodium diet (DASH diet) as well as increasing her metoprolol to 100mg BID. This will help decrease her blood pressure as well as decrease her HR into a normal range (60 to 100). Have JH follow-up with PCP in three months as well as report any additional side effects from BB (hypotension, dizziness, decrease libido, slow heart rate, and fatigue). DM: JH appears to have excellent control over her glucose levels with her current medication regimen. In order to enhance the effectiveness, JH should consider exercise/dieting to promote weight loss (discussed later). At her last office visit, her Hg A1C was 5.7%, which is well below goal (<7%). Goals for JH include: maintain home medications. Congratulate JH on her tight glucose control and have her continue her current regimen. Asthma: JH did not complain of any notable asthma exacerbations in the recent past. Goals for JH include: maintain home medications. Have JH continue her home medications by using the fluticasone twice daily as well as the albuterol for exacerbations. Iron Deficiency Anemia: JH stated that she has not taken her iron supplement lately because she ran out of her medication and had no remaining refills. Current CBC s display low Hg and Hct levels, which would be indicative of anemia. JH has not complained of any additional tiredness or fatigue. Goals for JH include: re-start iron supplement, monitor Hg and Hct levels. JH was given a new prescription of ferrous sulfate, which should allow her Hg and Hct levels to return to a normal level. CBC s should be re-checked at her next appropriate office visit. Obesity: JH is well over-weight (IBW unavailable as a height was never gathered upon admission). It is important to stress to JH that obesity is a risk factor for many disease states, including HS (even grants a more severe prognosis). Goals for JH include: begin healthy diet, begin mild exercise program, lose 1-2 lbs per week, follow-up with a lipid panel and utilize lipid lowering medication if needed. JH needs to be motivated to take control of her weight. Give incentives for her to begin eating healthy as well as starting an exercise program. Stress the importance of a healthy weight to avoid future diseases. JH should start will mild exercise and increase her level as she feels appropriate and safe. Order lipid panel at next appropriate office visit to obtain a new baseline and determine if pharmacotherapy is warranted. GERD: JH did not complain of any symptoms related to GERD. Goals for JH include: decrease use of Prilosec (omeprazole) if symptoms are not present. Since omeprazole is only indicated for 14 days, it is appropriate to stop the medication. Counsel JH on the fact that GERD like symptoms may return for a day or two after discontinuing the medication, but that they should resolve on their own. If symptoms persist, consider using an H2 antagonist such as Zantac (ranitidine). Bipolar Disorder: Currently managed by PCP and does not appear to be on any pharmacological intervention. DISCHARGE SUMMARY: JH was discharged from the hospital on Monday (admitted the previous Thursday evening). Medications: Rocephin (ceftriaxone) 2g q24h IV Vancocin (vancomycin) 1.5g q12h IV

5 REFERENCES: Lopressor (metoprolol) 100mg po BID Proventil (albuterol) 2 puffs q4h PRN Remicade (infliximab) 1275mg q6 weeks Ultram (tramadol) 50mg q6h PRN pain Delage M, et al. Efficacy of Infliximab for Hidradenitis Suppurative: Assessment of Clinical and Biological Inflammatory Markers. Acta Derm Venereol. 2011; 91 (2): Kamp S, et al. Sebaceous Gland Number and Volume is Significantly Reduced in Univolved Hair Follicles from Patients with Hidradenitis Suppurative. Br J Dermatol. 2011; Epub ahead of print. Lexi-Comp Online Yazdanyar S and Jemec GB. Hidradenitis Suppurativa: A Review of Cause and Treatment. Curr Opin Infect Dis. 2011; 24 (2):