Clinical Portfolio

 

Initial Visit Interview
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Password (PIN#):
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Patient Initial:
Date of Visit:
Patient Age:
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Reason for Visit:	"She's got a rash and it's not getting any better."
History of Present Illness:	This 2-month-old female patient was brought to KU medical center on 10/2/08 for a rash on her scalp. The patient would wake up with caked blood behind her ears. She was diagnosed as having seborrheic dermatitis and was sent home on Nizoral shampoo. Three days later the patient is brought to CMH because the rash has now spread from her head to her face, neck, chest, arm pits, diaper area, and back. The patient is admitted for a low-grade fever and persistent, worsening rash, with an index of suspicion of possible staph superinfection. The patient has been eating well, having good wet diapers, but has been crying more than usual. Mom denies fevers at home, no vomiting or diarrhea. She does have some upper airway congestion and rhinorrhea. Her stools are loose and yellow, which is consistent with her being breast-fed. She also gets Similac supplements while in daycare.
Past Medical History:	None
Educational, Occupational, Social, Family History:	This patient was born vaginally at 39 weeks gestation. There were no complications, no preeclampsia, or gestational diabetes. Mom believes herself to be GBS negative. She did not receive antibiotics during labor. Denies h/o HSV. Mom came over 2 years ago from Mexico to visit her father and never went back. Her only family support was her father and her maternal uncle. She is currently 18 years old and a senior in high school. When she became pregnant her father was no longer supportive and not involved in her life. She went to live with her boyfriend who is the father of this patient. He is 19 years old. After the childs birth, the boyfriend (father of patient) became physically abusive towards the mother. He also placed the child in his car without a car seat. Mom grew up in a domestically violent home and decided to remove herself and child from this situation. With the help of high school counselors she moved to a domestic violent shelter. She also spent a short period of time living with her uncle. It was decided that the domestic violent shelter could provide her with better resources and support. Mom speaks some English, but there is a language barrier. Patient’s immunizations are current per mother.
Surgical History:	None
Diet & Exercise History:	Breast and formula fed.
Pt. Understanding of Condition:	Mom understands that there is an infection, but I am not sure she understands the role of proper hygiene to prevent reoccurrence. Daycare is a big issue, and Social Services is involved.

Physical Exam
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Allergies, Intolerances & Reactions:	NKDA
Social Drug Use (alcohol, caffeine, tobacco, other):
Preceptor Comments #1:
Very interesting background. This would have been an interesting rash to see. What you've described is nothing like I've ever seen before.

Laboratory Data
DATE:				DATE:	10/05/08	10/14
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Additional Lab Data: (Please calculate Ideal Body Weight and Creatinine Clearance)		Peripheral blood culture + MSSA in one vial only. Skin Aerobic culture +MSSA and Streptococcus pyogenes Grp A. Negative for both skin & blood fungus. UA negative. wt is in 75th percentile per CDC growth chart for girls from birth to 36 months of age.

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DATE:	10/05/08	10/14
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Patient Clinical Problem List & Care Plan - Prioritized Medical Problem List
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Describe each problem and identify the therapeutic goal and specific endpoints. Support your identification of each problem with evidence from the literature. For each problem make recommendation and identify recommended monitoring parameters. Be sure to document the outcomes!

Pharmacotherapy Problem #1

Problem #1:MSSA sepsis

Medications used to treat problem #1:

Clindamycin (Cleocin) 55 mg IV q6h x 10 days.

Assessment of patient's current therapy:

Only one blood culture came back positive for MSSA. WBC normal, but differential slightly elevated (not quite sure it constitutes a left shift). Max temp 38.0 (100.4 ºF). I.D was consulted to evaluate if this was a contaminate vs true sepsis. The I.D. physician called it sepsis. I’m on the fence with this call. On one hand she does have MSSA on the skin so she could have a disseminated blood infection due to all of the swelling and erythremia. On the other hand it would be easy to contaminate a vial of blood during collection. She does not present as a picture of sepsis on admission to ER. Anyway, the call was made and the decision to use clindamycin empirically was appropriate since it covers CA-MRSA, MSSA, Strep, and anaerobes. Once the cultures and sensitivity results were reported as one blood vial + MSSA and skin cult + MSSA (normal skin flora) and Streptococcus pyogenes (Group A) the sensitivity panel was resistant to PCN-G but sensitive to everything else tested. Oxacillin could have been a good alternative. The continued use of clindamycin is still appropriate. The dose of 40 mg/kg/day divided q6h is correct, and she is dosed appropriately. The only point I disagree with is the statement made by the I.D. physician, which states “Her current social situation and the poor PO absorption of clindamycin will prevent VM from leaving the hospital for antibiotic treatment at home”. Her social situation may indeed be a problem, but clindamycin has great PO absorption. It is 90% bioavailable and only takes 60 minutes to reach peak serum concentrations (Actually, the IV is dosed higher than the PO, I always assumed this was related to the severity of illness rather than bioavailability of PO). This patient could have easily gone home on 10/8 as planned prior to the I.D. consult. She end up staying until 10/15 just for IV clindamycin therapy.

Patient goal and specific endpoints:

Resolution of sepsis.

Supportive medical evidence from literature:

The Sanford Guide to Antimicrobial Therapy 2008, 38th ed. David Gilbert et.al.

Recommendations to reach goal:

Complete full 10 days of therapy. I would have switched her to PO therapy on 10/8 .

Monitoring parameters and frequency:

Vital signs with each shift change. WBC w/differential on several consecutive days to monitor for disease resolution prior to discharge. Childs behavior, sleeping pattern, feeding pattern and urine output daily. Bowel pattern, color, odor, and consistency with each movement. Subjective and objective scalp and skin monitoring for color, edema, & texture for treatment evaluation.

Intervention documentation and outcome:

Intervention: parent education on antibiotic side effects, i.e. diarrhea. Report any bowel changes or fever to physician immediately. Monitor skin condition, if there is any worsening of condition then call physician. Strict guidelines for daycare. They must change her diaper at every soiling. Documentation: word document reviewed with CMH preceptor. Outcome: parent awareness, and early intervention should a secondary infection occur.

Pharmacotherapy Problem #2

Problem #2:Seborrheic dermatitis with secondary Strep & Staph infection.

Medications used to treat problem #2:

Clindamycin (Cleocin) 55 mg IV q6h x 10 days. Mupirocin (Bactroban) 2% topical ointment applied to left earlobe TID until healed for infection. Ketoconazole (Nizoral) 2% topical shampoo to scalp daily for seborrheic dermatitis. Compound of 1:1 hydrocortisone (various generics) 2.5% ointment and ketoconazole (Nizoral) 2% cream. Apply to plaques on face, neck, chest, back, diaper area, & arms BID. Mineral oil (various generics) to scalp BID to loosen crust and moisturize scalp.

Assessment of patient's current therapy:

Clindamycin therapy discussed above, and is appropriate. Mupirocin is appropriate for Staph and Strep and the dermatologist was worried about the scabbing of the left ear and impetigo. Using the hydrocortisone and ketoconazole combination I don’t understand. All fungal cultures were negative, and using hydrocortisone on almost her entire body makes me question absorption, especially with inflamed skin. With that being said however, her bottom is flaming red and this is probably only going to be used until we can get this inflammatory process under control. A secondary candida infection is most certainly possible in the diaper area, so use of ketoconazole could be for preventions sake. Mineral oil to help remove the thick, crusty, scabs on her scalp is appropriately used as a cleaning tool. It is not rubbed on scalp and left on. It is being used on gauze to help loosen the above-mentioned crust. I saw this patient for 2 consecutive weeks during rounds and during my consult with her mom. The difference between the first time I saw her and the second was incredible. The first time I saw her you could literately pull chunks of crust off her head and neck. The nurses contacted the physician stating that bugs were seen on her. No lice or body louse were identified. Simply bathing the child resulted in an improvement in her temperament. Her skin was vibrant red and oozing. I thought her head had ointment caked on it, but it was her cradle cap. The second time I saw her she looked like a happy little girl, smiling and cooing. Her skin was light pink, but her buttocks were still red, but her head was almost cleared of the cradle cap. She had a small area of alopecia.

Patient goal and specific endpoints:

Proper application of creams and ointments. Prevention of reoccurrence with proper hygiene.

Supportive medical evidence from literature:

Elish D, Silverberg NB. Infantile seborrheic dermatitis. Cutis. May 2006;77(5):297-300 The Sanford Guide to Antimicrobial Therapy 2008, 38th ed. David Gilbert et.al.

Recommendations to reach goal:

Apply creams and ointment as directed. Follow recommended personal hygiene recommendations. Change diapers as soon as they are soiled (urine or fecal). Contact physician immediately for any changes in bowel that suggest secondary infection like color, odor, quantity, or frequency. Monitor skin for color and texture. Report any redness, swelling, or scaling. Report any temperature, measured or tactile.

Monitoring parameters and frequency:

Daily monitoring of diaper area for redness, swelling, or skin breakdown. Daily monitoring of bowel habits as described above. Ask day care for a record of diaper changes and times creams/ointments were applied.

Intervention documentation and outcome:

I used both verbal and demonstration techniques to educate mom on proper use of creams and ointments. The dermatologist wants her to apply the compounded cream and then apply a thin layer of petroleum jelly over the top to keep the diaper from rubbing it off. Since there is a language barrier, even with her high school counselor present, I placed a thin of non-medicated cream on the top of my hand, then applied a thin layer of Vaseline over it, and then demonstrated proper hand washing technique. (I am amazed how many people do not know how to do this). Mom acknowledged proper technique and was very pleased to have the education. The school counselor stated that the patient’s daycare is being moved to a location closer to school so the mom can check in on her more often during the day. Documentation in word document format discussed with CMH preceptor. Outcome: parent education on proper application of ointment and MOA of drugs prescribed.

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Pharmacotherapy Problem #5:

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Pharmacotherapy Problem #6:

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Preceptor Comments #2:

Both your pharmacotherapy problems look great! Your "Assessment of current drug therapy" is excellent in the Seborrheic dermatitis problem. When you first mentioned the combo cream, the first thing I thought of was systemic absorption of the steroid, especially because of the inflamed skin. If hydrocortisone is used in infancy, it is usually a 0.5% concentration, so the 2.5% was concerning and I was pleased to see you address it in this section. I also liked your monitoring recommendation of mom getting a report of diaper change times / med therapy application times from the daycare. Holding them more accountable may or may not help, but they will hopefully be more diligent knowing that the information is expected.

Drug Therapy Progress Notes:
Pt: VM		Pharmacist:		Location:
LIST - Date - Problem - Actions:
1:	Visit #1 date 10/14/08 I stayed late so I could visit with mom. She goes to school and does not have any transportation so she has to wait for someone at school to bring her to the hospital. Today, her counselor is with her. Her counselor speaks some Spanish, and the patient speaks English with a heavy accent and does not understand medical jargon, but is able to converse on a basic level. My goal for this visit is to properly educate her on how to apply the topical cream and cover it with petroleum jelly. This was requested of pharmacy during rounds today. First we covered proper handwashing with a demonstration at the sink. I am actually quite proud of myself for remembering how to count to 15 in Spanish for the 15 seconds it takes to properly rub hands together. She is quite amused by me. We then applied a non-medicated cream (I used baby lotion, and she knew this was just for demonstration, and that she would be applying the actual medication to the baby) and then the Vaseline. She then demonstrated this on her own hand, and then we washed our hands again, only this time she counted to 15 in English. I love this girl. We talked about diarrhea and how it could be a sign of infection if it occurred often enough, and we also covered that soft stools once or twice more than normal could also be normal after antibiotics. She could verbally state that she knew that once or twice daily is OK but not more than 3 episodes per day. We also talked about color, and odor. Green, foamy, smelly is bad, call the doctor. We talked about her right to ask day care for a record of diaper changes and medicine applications. She will show them how to wash hands and apply cream and Vaseline. I explained that the cream was a combination of 2 medications for fungus an inflammation. I did not expand on more than this due to the language barrier. I feel that she has a handle on the information presented.
2:	Subjective: per mother this 2 month old female child has a 2-week history of a rash. She brought her to Ku med center 2 days ago for a low-grade fever and worsening rash. KU diagnosed the patient with seborrheic dermatitis of her scalp and prescribed ketoconazole shampoo. The rash advanced and spread to her face, ears, neck, armpits and chest. Mom brought patient to CMH. Immunizations are up to date per mom. Objective: Temp: 38 Hr:134 RR:28 BP:87/54 WT 5.5. CBC: WBC 11.99, Hgb 10.1, Hct 29.6, plt’s 685 (high). Abs Imm. Gran 0.05 (high) blood cx pending. Erythematous, edematous, red rash involving the entire perineum, leg folds, neck, face, outer ears bilaterally. Scalp has thick, scaly, yellow, plaques. Thick white discharge collected in the neck folds. Patient is malodorous. Assessment: Rash likely started as seborrhea, now with concomitant candidal appearing rash, with possible staph/strep superinfection. Poor hygiene. Plan: admitted patient due to low-grade fever and progressive rash. Start Nizoral shampoo for the scalp 2x/week (dermatology consult changed this to daily). Nystatin cream topically to affected areas qid. Hydrocortisone cream 2.5 % to affected areas qid. Super duper diaper doo to peri area with each diaper change. Clindamycin 30 mg/kg divided q6h IV for empiric coverage of staph/strep. (side-note: both I.D and dermatology consults changed the medications that were originally ordered per admit physician).
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Portfolio Summary - Summarize this patient's case in your own words and email to Professor Dahm at sdahm@ku.edu. Provide a brief introduction to the case and tell us your impression of the overall care of this patient.
Preceptor Comments #3:
Fantastic overall! Thanks, Amber Lucas, PharmD, BCPS

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