ALBANY STATE UNIVERSITY COLLEGE OF SCIENCE AND HEALTH PROFESSIONSFAMILY NURSE PRACTITIONER PROGRAMEpisodic Care Information SheetSTUDENT NAME: Alexander WarrenDATE: 02/19/2015

PT. J.T.RRACE: BlackA AGE: 62

SEX: Male

ENCOUNTER DATE: 02/17/2015

SUBJECTIVE Chief complaint/concern: I have a rash all over my body and blisters on my hands.HPI: 60 year old African American widowed male presents today for an evaluation of a rash that, he states, began three days ago. Patient states that it began on his chest and was very pruritic. Yesterday, per the patient, the blisters began forming on the palms of his hands and the soles of his feet. He has taken OTC Benadryl for the itching with no relief. Past Medical History:CAD.

HTN.

DM type II.Hyperlipidemia. Status post CABG X 4 in 2010.Allergies: NKDACurrent Medications: Simvastatin 40 mg daily, Amlodipine 5 mg daily, Bydureon 2 mg weekly, Metformin 500 mg twice a day Immunizations: Up to date.Family Health Hx: Mother and father are obese. Mother had CVA in her 50s. Father with CHF and died from MI in his 60s.Social History: Widower since wife passed away last year. Lives with his son who is single. Has three children, all live in the Valdosta area. Denies use of alcohol or drugs. The patient is a smoker, states he smokes about a pack a day X 8 years.Review of Systems: General: Denies fever, chills, difficulty sleeping, unintentional weight loss/gain, or fatigue.EENT: Denies any visual disturbances, headaches, dizziness, ear pain/drainage. Denies any nose bleeds or other nasal discharge. Denies sore throat, swelling/pain of the tongue, or bleeding of the gums.Respiratory System: Denies any wheezing, shortness of breath, cough, or mucous production.

Cardiovascular: Denies any palpitations, chest pain, swelling of extremities, coldness in extremities, or exertional dyspnea. Gastrointestinal system: Denies any pain of the abdomen, nausea, vomiting, change in appetite, indigestions, constipation, or diarrhea. Denies any blood in his stools.Genitourinary system: Denies nocturia, urinary frequency/urgency, incontinence, or urinary retention.Skin: Complains of pruritic rash that first appeared on his trunk 3 days ago. He states vesicles began to form on the palms of his hands and sole of his feet 1 day ago. The rash that began on his trunk has now spread almost completely across his entire body but has spared his face. He denies changing detergents or coming into contact with any foreign chemical. He denies any drainage from the lesions but states that vesicles are very painful. He denies any bruising or hair changes. Endocrine: Denies any heat or cold intolerance. Denies any hair changes. Denies any dry skin or excessive thrist.Musculoskeletal System: Denies any joint pain, swelling, or stiffness. Denies any difficulty walking, muscle pain, or cramps.Neurologic System: Denies any change in mental status, increase forgetfulness, or nervousness.Pscyh: Denies insomnia, anxiety, or depression.ObjectiveBP: 128/86 O2 sat: 95% P: 82 R: 18 Temp: 97.2 HT: 70 inches Wt: 218 pounds Physical Examination.A. General: Healthy appearing 60 year old African American male who is well developed and well nourished in appearance. No distress or anxiety noted. B. Head: Normocephalic. Normal male pattern baldness noted. Negative TMJ. No lymphadenopathy or sinus tenderness noted. C. Eyes: PERRLA. D. Ears: Tympanic membranes intact and pearly gray in color. No fluid or irritation noted. No masses or lesions.E. Nose: Septum midline. Nasal turbinates not swollen and nasal passages are clear. Mucosa pink and moist. No polyps noted

F. Mouth: Dentition in good repair. Mucosa pink and moist. Tongue midlines with no lesions or swelling noted. Gums pink with no disease or bleeding noted.G. Neck: No lymphadenopathy noted. Thyroid reveals no enlargement or masses. Trachea midline. Symmetrical and supple.H. Skin: Fine macular popular rash noted that covers almost the entire body. Rash only spares the face, palms of hands, and soles of feet. The patients skin is otherwise irritated and inflamed from the patient scratching. There appears to be a secondary infection on the patients ear from where he has scratched a lesion. There are small vesicles noted on the patients palms of hands and soles of his feet. They all measure around 1 cm x 1 cm in size and are filled with clear fluid. The patient walks with a limp, stating that it hurts to stand on the lesions. I. Respiratory: Chest rise and fall is symmetrical. Respirations are unlabored. Breath sounds are clear. J. Cardiovascular: S1 and S2 heard. No murmurs, rubs, or gallops noted. Rhythm regular.K. GI: Abdomen reveals no distention. No pulsations noted. Bowel sounds noted in all 4 quadrants. No tenderness to palpation. L. Gu: Deferred.M. Lymphatic: No lymphadenopathy or tenderness noted.N. Musculoskeletal: Normal gait. Full range of motion and denies pain with movement. No crepitus noted.

O. Neuro: Cranial nerves II-XII intact. Patient alert and oriented. Full strength noted in upper and lower body.

Lab Findings/Diagnostics: CMP normal, CBC revealed only slightly elevated eosinophils at 500, ESR slightly elevated at 28DIFFERENTIAL DIAGNOSIS;

1. Contact dermatitis.2. Medication reaction. Patient started on Bydureon a week ago.

3. Atopic dermatitis.Assessment/Final Diagnosis: Medication reaction due to Bydureon.Plan: 1. Given Depo Medrol shot IM in office 80 mg.2. Referred immediately to dermatology. Called and sent patient there immediately. The dermatologist made the final diagnosis.

3. Stop Bydureon.

4. Take lukewarm baths to soothe skin.

5. Keep skin infection on ear clean and dry. Should clear up on its own but follow up in 3 days if no improvement.

6. Follow up in one week to consider new options to replace Bydureon.Health Promotion Issues and EducationUse sunscreen when working outside to reduce the risk of skin cancer. If you notice any

side effects from new medications call the office or come in immediately. Do not scratch lesions

as this can cause secondary infections which could lead to serious problems. Keep current

infected area clean and dry. Avoid abrasive chemicals that could irritate the skin, use detergentsthat are free from colors and scents. Encouraged smoking cessation. Risks of continued

smoking discusses and benefits of cessation discussed. Discussed ADA diet and handouts were

given. Encouraged to keep a food diary and a blood sugar log.

Discussion: My preceptor and I were very concerned upon visualizing the patient. The rash was

very severe and the patient was in obvious discomfort. He initially did not complain about

the vesicles on the palms of his hands or the soles of his feet so it appeared to be just a diffuse

rash across his body. With that presentation only, and because the rash spared his face,

it appeared to be contact dermatitis. It was not until he stood and began walking that we saw him

limping. When asked why he was limping, he showed us the vesicles. This made it very clear

that it was a systemic problem. We were aware that the patient had recently been started on

Bydureon but this was not a reported side effect. Bill (my preceptor) happened to have the

number for the representative for this medication. Once called, the representative stated this had never been reported as a symptom. I did some researching myself on reactions to Bydureon and found the most common reactions are hypoglycemia 8%, injection site reactions 17.1%, pancreatitis, thyroid tumors, and drug interactions (Painter, 2013). Adverse drug events (ADE) are more common than I thought, depending on the patients age, adults have a 5.27% chance of

having and ADE while the elderly have a 16.1% (Tache, 2011). The patient was given a Depo shot 80 mg IM in the office in an attempt to decrease the inflammatory process. Bill then called a dermatologist and sent the patient directly to his office. The dermatologist diagnosed the patient with a drug reaction that was probably due to the Bydureon. I feel this was the appropriate treatment. It was very concerning that the patient did not inform us about the vesicles on the bottom of his feet as this symptom is what alerted us to the problem being systemic. I also feel that Bill was correct in sending the patient to a specialist instead of treating the patient himself.

Painter, N. A., Morello, C. M., Singh, R. F., & Mcbane, S. E. (2013). An Evidence-Based and Practical Approach to Using Bydureon in Patients With Type 2 Diabetes.The Journal of the American Board of Family Medicine,26(2), 203-210. doi: 10.3122/jabfm.2013.02.120174Tache, S. V., Sonnichsen, A., & Ashcroft, D. M. (2011). Prevalence of Adverse Drug Events in Ambulatory Care: A Systematic Review.Annals of Pharmacotherapy,45(7-8), 977-989. doi: 10.1345/aph.1P627COMMENTS Assignment Accepted

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