PHARMACOLOGY CONFERENCE

1. PHARMACOLOGY CONFERENCE Andal, Ang, J, Ang JM, Ang, K., Aningalan, A.

2. General Data • C.R. • 1 y/o • Male

3. Chief Complaint: Swelling of the L arm

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. Review of Systems (-) heat-cold intolerance, polydipsia, polyphagia, polyuria (-) headache, speech disturbance, seizures (-) anxiety, depression, confusion

11. 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.

12. 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.

13.  Personal History Feeding 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

14.   24-Hour Food Recall

15. 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

16. Past Medical History: • No previous hospitalizations/major illnesses • No previous surgeries • No previous blood transfusions

17. Immunizations: • incomplete immunization; unrecalled dates • BCG1 • DPT123 • OPV123 • HepB123 • Measles • HiB1

18. Family History: • (+) Diabetes Mellitus – maternal great grandmother, maternal aunt • (+) Hypertension – maternal grandmother • (+) asthma – maternal grandfather • (-) PTB, Cancer, Hematologic diseases, Goiter

19. Family Profile

20. 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)

21. Physical Examination General: Alert, awake, irritable, not in cardiorespiratory distress, well-nourished, well-hydrated Vital 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 soles Head: No gross head deformities, HC = 53 cm (z-score: +3), no lesions on the head, equally distributed fine black hair, closed fontanels

22. Physical Examination Pink palpebral conjunctivae, pupils 2-3 mm ERTL, anictericsclerae No 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

23. Physical Examination Heart: Adynamicprecordium, 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

24. 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.

25. 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 light CN3, 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

26. 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

27. Symptom, signs and laboratory finding found in the least number of disease • Fluctuant Mass

28. Differential Diagnosis • V—Vascular conditions of the skin like postphlebitic ulcers that cause a discharge • I—Inflammatory conditions of a noninfectious nature like erythemamultiforme, pyodermagangrenosum, 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 periarteritisnodosa 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

29. Infectious Disorders (Specific Agent) • Glanders abscess • Histoplasmosis, African • Milkers nodules • Mycobacterium marinum/granuloma skin • Skin infections/Pyoderma • Toxoplasmosis, congental • Whipples disease • Chromoblastomycosis/chromomycosis • Farcy/CutaneousGlanders • Cutaneous fungal infection • Immune deficiency, acquired (AIDS/HIV) • Infestations/fleas/mites/lice • Sporotrichosis • Cryptococcosis • Glanders (malleomycesmallei) • Loiasis/Loa loa infestation • American leishmaniasis/cutaneous • Angiomatosis, bacterial Bartonellosis • Blastomycosis • Cytomegalic virus, congenital

30. Infected organ, Abscesses • Adenitis/lymph node • Furunculosis • Abscess, subcutaneous • Carbuncle • Pyodermagranuloma (vegetans)

31. Granulomatous, Inflammatory Disorders • Panniculitis

32. Neoplastic Disorders • Hemangioma • Lipoma • Leukemia, acute • Melanoma, malignant • Hodgkin's disease • Kaposi Sarcoma

33. Allergic, Collagen, Auto-Immune Disorders • Juvenile rheumatoid arthritis/Stills d • Erythemanodosum • Juvenile chronic arthritis (rheumatoid) • Neonatal subcutaneous fat necrosis • Panniculitis, nodular nonsuppurative • Polyarteritisnodosa • Rheumatoid arteritis/vasculitis • Rheumatoid nodule • Polyarteritisnodosa, infantile

34. Metabolic, Storage Disorders • Gout • Tophi/Gouty tophi • Pseudogout syndrome • Amyloidosis, primary nonhereditary

35. Congenital, Developmental Disorders • Arteriovenous malformations • Cavernous lymphangioma • Angioma/cutaneous • Dermoid cyst

36. Hereditary, Familial, Genetic Disorders • Ehlers-Danlos syndrome • Gardner syndrome • Neurofibromatosis • Tuberous Sclerosis • Lipodystrophy, generalized

37. Anatomic, Foreign Body, Structural Disorders • Sebaceous cyst • Soft tissue foreign body/subcutaneous • Keloid • Joint ganglion

38. Approach • Smear and culture • skin biopsy • Serologic tests • cultures on special (fungi and parasites)

39. Others • CBC (systemic infection) • Sedimentation rate (systemic infection, collagen disease) • Tuberculin test • VDRL test (primary or secondary syphilis) • X-ray of area involved (abscess, osteomyelitis) • ANA analysis (collagen disease) • Skin test and serology for fungi • Biopsy • Muscle biopsy (collagen disease, trichinosis)

40. COURSE IN THE WARD

41. 1ST Hospital Day • IVF: D5 IMB 500mL to run at 12-13 gtts/min • Request for: • CBC with platelet • Gram stain of wound discharge • Culture and sensitivity of wound discharge • Medications: • Clindamycin 150mg/slow IV infusion (32.1mg/kg/day) over 30 mins. now then every 8 hrs. ANST • Amikacin 100mg/slow IV push over (21.4mg/kg/day) 30 mins. every 8 hrs. • Paracetamol 250mg/5mL, 4 mL every 4 hours for Temp. > 38.5°C or for pain (14 mg/kg/dose ) • Refer to Pediatric Surgery for further evaluation and management

42. 1st Hospital Day • Incision and Drainage of Abscess • 20cc purulent discharge • Specimen sent for GS/CS • For daily COD

44. 2nd Hospital Day • D1-2 • Clindamycin 150mg/slow IV infusion (32.1mg/kg/day) over 30 mins. now then every 8 hrs. ANST • Amikacin 100mg/slow IV push over (21.4mg/kg/day) 30 mins. every 8 hrs. • Decreased to D5 IMB 500mL to run at 9-10 gtts/min • Patient was transferred to malward • IVF to consume • Increase oral fluid intake

46. 5th Hospital Day • D5-6 • Clindamycin 150mg/slow IV infusion (32.1mg/kg/day) over 30 mins. now then every 8 hrs. ANST • Amikacin 100mg/slow IV push over (21.4mg/kg/day) 30 mins. every 8 hrs. • 0.65% NaCl Nasal drops 2-3 gtts/nostril then suction Q6

48. 14th Hospital Day • Day 14 • Clindamycin 150mg/slow IV infusion (32.1mg/kg/day) over 30 mins. now then every 8 hrs. ANST • Amikacin 100mg/slow IV push over (21.4mg/kg/day) 30 mins. every 8 hrs. • Disharged • Final Diagnosis: Abscess secondary to MRSA • Take Home Medications: • Co-trimoxazole 400mg 180mg/5mL, 4mL Q12 to complete for 2 weeks • Mupirocin ointment, apply on affected area TID • Anticipatory Guidance • Immunization update • For follow up at OPD on Oct 10, 2010

49. Antibacterial activity of honey against community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) Maedaab et. Al Complementary Therapies in Clinical Practice (2008) 14, 77–82

50. Introduction • There has been increasing reports of community acquired MRSA amongst healthy individuals, who have no hospital association • Predominant presentation is associated with skin and soft tissue infections, particularly folliculitis, pustular lesions and abscesses. • Risk factors for its acquisition include close physical contact, abrasion injuries and activities associated with poor communal hygiene (e.g. sharing towels).