CASE PRESENTATION

Dermatology/MSK

Submitted by:
Gonzales, Christine Joy
Hamis, Rashid-Ali
Ibbang, Darwana
Ilano, Krizha
Muluk, Sahar
Nurilla, Noreen
Sebastian, Elaine Marie
Tahsin, Sulaiman
Torino, Nikka Lorence
Valdez, Charlene Mae

October 25, 2017

GENERAL DATA
Name: S.C.
Age: 17 years old
Sex: Male
Address: Baluno, Zamboanga City
Civil status: Single
Occupation: Sardine factory worker
Religion: Islam
Nationality: Filipino
Educational attainment: 2nd year High School

Source and reliability: Patient, his mother and brother, 90% reliable.

CHIEF COMPLAINT: Loose bowel movement

HISTORY OF PRESENT ILLNESS
Seven days PTA, the patient experienced on and off undocumented fever. The patient
took paracetamol 500mg once a day but afforded no relief.
Three days PTA, the patient had LBM 10 times per day, 2 tbsp per episode,
characterized as watery and mucoid in consistency with blood streak noted in first day. It was
associated with epigastric pain and vomiting every time he eats. The volume and content of the
vomitus depend on the amount and the kind of meal taken. There was no blood noted in the
vomitus. Other associated symptoms include headache, eye pain, red eye, dysphagia and non-
productive cough. Whitish spots were also noted by the patient on his buccal mucosa.
Two days PTA, the patient complained of itchiness on his forehead and noticed
appearance of rashes. The rashes were scattered and small described as flat but some were
raised approximately less than 1cm in diameter each, reddish in color and itchiness were noted.
Accordingly, eruption of rashes started on his scalp area. Furthermore, the patient started to
develop myalgia and still with persistence of LBM and vomiting. The patient also complained of
body weakness. It was revealed that the patient had a close contact with a relative with a viral
exanthem disease. Herbal treatment of an unrecalled root plan concoction was given to him
but afforded no relief.
Hours prior to admission, the patient complained of difficulty of breathing and
generalized weakness. His rashes became generalized, spreading from his trunk to his
extremities. There were persistence of LBM and vomiting. Hence, he decided to seek medical
consult at ZCMC-ER and was subsequently admitted.

PAST MEDICAL HISTORY

The patient has no known allergies, no previous hospitalization nor surgeries.
Furthermore, he is fully immunized according to the mother.

FAMILY HISTORY
There is family history of hypertension. No known family history of diabetes, asthma,
and cancer.

PERSONAL AND SOCIAL HISTORY

The patient is the 9th of the 12 siblings. He already stopped in his studies and work as a
factory worker in a sardine factory. There is nobody in his working place who has
exanthematous disease or diarrhea as well as in their locality.
 Their source of drinking water is from the line of water district usually without boiling or
any sterilization process.
The patient has 1.5 pack year history of smoking but denies drinking alcoholic
beverages. Also, the patient denies taking drugs as well as engaging in intimate relationship.
As for the diet of the patient, he is fond of drinking softdrinks and curls. Daily diet
usually consists of fish and rice.

REVIEW OF SYSTEM
General: (-) weight loss (-) loss of appetite
Skin: (+) itchiness
HEENT:
Head: (+) headache (+) dizziness
Eyes: (+) eye pain (-) use eyeglasses
Ears: (-) difficulty of hearing (-) tinnitus
Nose: (-) sinusitis
Throat:(+) sore throat (+) dysphagia
Neck: (-) neck pain
Respiratory: (-) chest tightness (+) difficulty of breathing
Cardiovascular: (-) palpitation
GIT: (-) trouble swallowing (+) nausea (+) pain
GUT: (-) dysuria (-) nocturia (-) urinary incontinence (-) hematuria
Peripheral Vascular: (-) leg cramps
Musculoskeletal: (-) bone pain (-) joint pain
Hematologic: (-) easy bruising
Endocrine: (-) heat or cold intolerance

PHYSICAL EXAMINATION
General Survey: The patient is awake, lying down with 2 pillows on head, responsive and not in
respiratory distress.
Vital Signs: BP 100/60 mmhg
HR 94 bpm
RR 47 cycles/min
Temp 38C
02 sat 98% with nasal cannula at 3L/min

Skin: The skin is warm to touch, normal skin turgor, and moderately dry. Skin lesion includes
confluent erythematous macules and papules over face, and widely distributed over trunk and
extremities. Skin lesions are non-blanching. Nail is pinkish and no cyanosis.

HEENT:
Head: The skull is normocephalic.
Eyes: Conjunctiva injection bilaterally, periorbital edema and eye pain. Pupils constrict 3mm,
equally round and reactive to light and accommodation.
Ear: No discharge, no ear pain.
Nose: Nasal mucosa pink, septum midline
Throat:Oral mucosa pink, there is a cluster of tiny whitish papules on buccal mucosa

Neck: There is nontender left submandibular lymphadenopathy

Thorax and Lungs:

Inspection: There was involvement of accessory muscles on inhalation but intercostals
rectractions were not assessed. The chest is symmetric with good expansion.
Palpation: Equal lung expansion.
Percussion: Both lungs are resonant on percussion.
Auscultation: Clear breath sounds on both lung fields.

Cardiovascular: Adynamic precordium. There are no heaves and thrills. PMI is at 5th ICS
midclavicular. Heart sounds are distinct. On auscultation, at the apex S1 is greater than S2, and
S2 greater than S1 at base

Abdomen: The abdomen is flat with normoactive bowel sounds. There is no palpable mass, no
tenderness on all quadrants. Liver span was not measured and no costovertebral angle
tenderness.

Muskuloskeletal: No edema. Normal Range of Motion

CLINICAL IMPRESSION: Acute Gastroenteritis; Viral Exanthem to consider Measles

Basis:
History Physical Examination
Acute Gastroenteritis :
Fever
Headache
LBM 10x mucoid with blood streak
Epigastric pain
Dysphagia
Vomiting
Measles: Whitish spots on buccal mucosa
Fever Generalized maculo-papular rashes
Headache Non-tender submandibular
Non-productive cough lymphadenopathy
Conjunctivitis Periorbital edema
Eye pain
History of close contact with relative with viral
exanthem disease
Rashes initially appeared on scalp area then spread
to the trunk
DIFFERENTIAL DIAGNOSIS
DDx for LBM Rule In Rule Out
Typhoid Fever Fever Fever usually ends after 4
Vomiting weeks but cannot be ruled
Epigastric pain out. Needs further
Headache laboratory testing
LBM 10x mucoid with blood streak
Appearance of rashes
Amebiasis Fever Cannot be ruled out. Needs
Vomiting further laboratory testing
Epigastric pain
LBM 10x mucoid with blood streak

DDX for Rashes Rule In Rule Out

Dengue Fever Fever Arthralgia
Vomiting No hemorrhagic
Epigastric pain manifestations like bleeding
Headache gums, epistaxis.
Eye pain Rashes initially appeared on
Myalgia scalp area then spread to the
Generalized maculopapular rash trunk
Infectious Mononucleosis Fever Palatal petechiae of the
Lymphadenopathy posterior oropharynx
Generalized maculopapular rash Tonsillar enlargement
Periorbital edema
Non-productive cough
Erythema Multiforme Fever Rashes usually start from the
Generalized maculopapular rash extremities symmetrically,
Non-productive cough with centripetal spreading.
History of LBM prior to eruption Papules evolve into
of skin lesions pathognomonic target or iris
lesions
PARACLINICALS
1. Complete Blood Count (CBC)
- This can determine the presence of infection in the patient. For measles, lymphopenia
and neutropenia is common and may be due to invasion of leukocytes by the virus, with
subsequent cell death. Leukocytosis may herald a bacterial superinfection. In infectious
mononucleosis, WBC count is usually elevated and peaks at 10,000-20,000/L during the
second or third week of illness. Lymphocytosis is usually demonstrable, with >10% atypical
lymphocytes.

2. Serum electrolytes
- Degree of dehydration and electrolyte derangement should be evaluated in this
patient. All the acute effects of watery diarrhea result from the loss of water and electrolytes
from the body. Water losses are also increased by fever. These losses cause dehydration (due
to the loss of water and sodium chloride), metabolic acidosis (due to the loss of bicarbonate),
and potassium depletion.

3. Serologic test
- Measles virus infection can be diagnosed by a positive serologic test for measles
immunoglobulin (Ig) M antibody, a significant increase in measles IgG antibody concentration in
paired and convalescent serum specimens by any standard serologic assay, or isolation of
measles virus or identification of measles RNA from clinical specimens, such as urine, blood,
throat, or nasopharyngeal secretions. The simplest method of establishing the diagnosis of
measles is testing for IgM antibody on a single serum specimen obtained during the first
encounter with a person suspected of having disease. Specific IgM antibodies are detectable
within 1-2 days after rash onset, and the IgG titer rises significantly after 10 days.

4. Stool exam
- The presence of blood or leukocytes in stool is a strong indicator of inflammatory
diarrhea. In amoebiasis, fecal findings include a psotive test for heme, a paucity of neutrophils,
and amoebic cysts or trophozoites.

5. Blood culture
- The definitive diagnosis of enteric fever requires the isolation of S. typhi or S. pratyphi
from blood, bone marrow, other sterile sites, rose spots, stool, or intestinal secretions. The
yield of blood cultures is quite variable; sensitivity is as high as 90% during the first week of
infection and decreases to 50% by the third week.

6. Chest X-ray
- The patient is in respiratory distress, and one of the site of complications of measles
infection is the respiratory tract. Pneumonia is a frequent reason for hospitalization, especially
of adults. The pneumonia is of viral origin in the majority of cases, but secondary bacterial
infection (most commonly casued by streptococci, pneumococci, or staphylococci) also
develops with some frequency.

MANAGEMENT
Acute Gastroenteritis
Oral Rehydration Therapy
Enteral Feeding and Diet Selection
Zinc Supplementation
Antibiotic Therapy

Measles
Supportive
o Antipyretics: comfort and fever control
o Airway humidification and supplemental oxygen: if with respiratory tract
involvement
o Oral rehydration
o Vitamin A: 200,000 IU