OS 216: Hematopoeisis and the Immune Responses
SGD 2: Rash
Allergology Consultants
TOPIC OUTLINE
I.
II.
Case 1 – Rash: Adverse Drug Reaction
Case 2 – Rash: Atopic Dermatitis
2
November 28, 2013
She does not preexisting illness, no known allergies, and no
previous hospitalizations and surgeries. She has been taking
Vitamin C 500mg OD >10 years.
CASE 1
Her mother is hypersensitive and a sibling has asthma. Andrea has
no vices and works as a call center agent. She had her menarche at
12 years old and her menses at regular monthly intervals for 3-5
days duration. Her last menstrual period was 13 days ago. She
denies OCP use.
Andrea is a 24-year old female who consulted at the OPD for
rashes. One week prior to consult, she experienced sore throat and
colds. She just rested and increased her water intake. On the day
of consult, she noted the appearance of red rashes on her body
and extremities. This prompted her to consult at the OPD.
She lives in a subdivision in San Pedro, Laguna. Her house is not
along a busy street. There are no vacant lots around and there is a
mango tree in the backyard. There are no pets at home. There are
curtains but no carpets in the house and in the bedroom. She
cleans the house using a broom.
Question 1: As part of your history taking, what additional
history will you elicit?
History of Present Illness

Onset. Identify when the patient first experienced the said
symptoms. Clarify if patient experienced this before.

Quality or character. Probe on the characteristics of the lesion:
was it pruritic, purulent, with advancing borders?

Distribution. Confirm if the rashes were localized at certain
areas of the body, or if they were found all over.

Chronicity of symptoms. Identify whether the symptoms were
recurrent or persistent.

Severity.

Progression. Were the present symptoms worse than when
they had first started?

Aggravating and alleviating factors.

Activity upon onset of symptoms.

Associated/ similar symptoms. Identify if there was lung or
systemic involvement.

Response to management (i.e. rest and increase in water
intake). Take note of any alleviation of symptoms as a result
of management, and to what degree.
Past Medical History

Infections

Atopy. Elicit history of asthma and allergies.

Previous surgeries and hospitalizations
Family History

Infections. This is important because the rash may have been
caused by scabies, which would otherwise affect the entire
household

Atopy.
Personal/ Social History History

Sexual History. Some STIs have characteristic rashes.

Employment. Elicit chemicals or substances that might trigger
symptoms.

Substance abuse

Lifestyle
Environmental History

Living Conditions

Activities/Hobbies
Medications

Ask the patient to enumerate the drugs she has taken. Were
they prescribed by the doctor or self-prescribed? How have
they altered the symptoms?
Five days prior to consult, she started to develop fever and cough
with yellowish sputum. She self-medicated with Paracetamol 500
mg/tablet, 1 tablet every 24 hours as necessary for fever.
A few hours prior to consult, with persistence of symptoms, she
started to take Amoxicillin 500mg/tablet. About an hour after taking
it, she started to feel itchy all over and started to develop hives.
She denies associated symptoms. She had no dyspnea, chest pain,
nausea/vomiting, no bowel or urinary changes, headache,
dizziness, loss of consciousness.
Mac, Thea, Larie
Question 2: Given the additional history, make a drug
chart.
uestion 1: As part of your history taking, what additional
history will you elicit?
Question 3: What part of the physical examination will be
pertinent in this case?
uestion 1: As part of your history taking, what additional
history will you elicit?
In making the drug chart, identify all medication that the patient has
taken. Specify the duration of use, and indicate the time when the
symptoms first appeared.









Red rashes on body and extremities
Sore throat
Colds
Relieved by rest and increase in water intake
Fever
Cough with yellowish sputum
Pruritus
Urticaria/Hives
History of atopy
Physical Examination
Conscious, coherent, not in respiratory distress
BP 120/80
HR 104 RR 20
T 38.5°
Pink conjunctiva, anicteric sclerae, (-) Eye discharge, (-) Tears,
(-) Angioedema
(+) Oral and lip discoloration, (+) Tonisollopharyngeal congestion,
(+) Purulent nasal discharge, (+) Yellow post-nasal drip, (+) Cervical
lymphadenopathy
Equal chest expansion, (-) Rales/wheezes
Apex beat at 5th ICS LMCL, Good S1 and S2 tachycardia
Regular rhythm, (-) Murmur
Abdomen flat, Normoactive bowel sonds, soft, nontender
Pink nailbeds, Full equal pulses
(-) Edema, (-) Cyanosis
(+) Blanching wheals all over, (+) Excoriations,
(-) Epidermal detachment or Nikolsky sign, (-) Insect bites
Question 4: Given the history and physical examination,
what is your diagnosis and your differentials? Give basis
for each.
uestion 1: As part of your history taking, what additional
The following
areyou
the elicit?
differentials for the patient’s case:
history will
1. Adverse Drug Reaction
The undesired or unintended responses to a drug that occurs
at doses appropriate to the drug. The reaction appears at
reasonable time after the administration of the drug.
2. Upper Respiratory Tract Infection
URTI are illnesses caused by acute infection in the nose,
sinuses, pharynx and larynx. Some of its symptoms include
colds, runny nose, sore throat and nasal congestion.
Page 1 / 3
SGD 2: Rash
Symptom
Red rashes on body
and extremities
Sore throat
Colds
Relieved by rest and
increase in water
uptake
Fever
Cough with yellowish
sputum
Pruritus
Urticaria/ Hives
History of Atopy
Tachycardia
Oral lip discoloration
Tonsillopharyngeal
congestion
Purulent discharge
Yellow post-nasal
drip
Cervical
lymphadenopathy
Blanching wheals all
over
Excorations
Adverse Drug
Reaction
Upper
Respiratory Tract
infection









Did the patient experience colds, nasal congestion,
rhinorrhea? (To rule out/in allergic rhinitis)
Did the patient experience difficulty breathing? (To rule out/in
asthma)
Did the patient experience frequent clearing of throat? (To rule
out/in post nasal drip)
From 1-2 years old, rashes would appear on neck, arms, and back
of knees after sweating. Symptoms would last for 2-3 weeks and
would appear usually during summer. Rashes are also after eating
chicken and shrimp. Symptoms persisted despite consulting
several doctors and complying with medications.
Joaquin also complains of nasal pruritus and sneezing but no
rhinorrhea. He does not have cough, fever, nor easy fatigability. He
has no petechiae, bruising, nor bleeding.
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Working Impression: Adverse Drug Reaction with concomitant Upper
Respiratory Tract Infection (URTI)
Question 5: Discuss the general principles of
management for this case.
for each.

Avoid
drug
possible
uestion
1: As
partif of
your history taking, what additional

Patient
history
will youeducation
elicit?

Future prudent use of the drug

Consider desensitization if presumed IgE-mediated or graded
challenge if non-IgE-mediated

For URTI, prescribe alternative medication other than
amoxicillin
CASE 2
Joaquin is 5-year old boy who was brought to the OPD with pruritic
rashes. At 8 months of age, patient would have dry, red scaly
plaques on the cheeks, and chin and diaper area. These would
temporarily relieved by bathing in lukewarm water and applying
unrecalled topical creams.
Question 1: What additional points in the history would
be pertinent to ask?
for each.
uestion 1: As part of your history taking, what additional
will
you
elicit?and symptoms recurrent?
history
Are
the
lesions

During which time of the day/month of the year do the lesions
manifest?

How long do the lesions persist per occurrence?

Are there other manifestations of atopy?

Do other family members have manifestations of atopy?

Are there other family members with the same symptoms?

What are the details of birth and maternal history?

What is the distribution of the lesions on the current consult?

What is the character of the lesions during the current
consult?

What is the pattern of the lesions during the current consult?

Is the patient taking any medications?

Did the patient consult a physician regarding the symptoms?

Did the patient undergo previous hospitalizations or surgery?

Did the patient have recurrent infection from 8 M.O. to 5 Y.O.?
(To rule out/in WAS)

Were there environmental, food or medical drugs that
triggered the occurrence of the lesions?

What is the color, consistency, and brand name of the topical
cream?

Did the topical cream relieve the pruritus and the lesions?

Did the patient self-medicate?

What are the aggravating/alleviating factors?

Did the patient experience fever and cough?

Did the patient experience bleeding? (To rule out/in WAS)
TRANSER, TRANSER, TRANSER

OS 216
He has no previous illness, no recurrent infection, no previous
hospitalizations or surgeries. His mother and older sister have
asthma. No other family members have pruritic skin disease.
He is the younger of two children. He was breastfed for 6 months
and was later started on Nestogen milk formula and semi-solid
foods at 6 months. He has no food preferences and has good
appetite.
He lives in a cemented house and is along a busy street. There are
no pets at home. The house is cleaned using a broom and wet rag.
Question 2: What will you look for in the physical
examination to diagnose this patient?
each. are the vital signs?
 for What
As Mental
part of Status
your history
 uestion
What 1:
is the
of the taking,
patient?what additional
will in/out
you elicit?
 history
To rule
atopic dermatitis:
o
What are the lesions’ characteristics?
o
Borders
Size
o
Symmetry
Color
o
Elevation
Pattern
o
Distribution
o
Are there any anterior neck folds?
o
Are there any Dennie-Morgan infraorbital folds?
o
Is cheilitis present?
o
Is ichtyosis present?
o
Is palmar hyperlinearity present?
o
Is keratosis pilaris present?
o
Are allergic shiners present?
o
Is pityriasis alba present?
o
Is xerosis (skin dryness) present?

Is scaling present? (to rule in/out psoriasis)

Do the lesions blanch upon pressure?

(to rule in/out vasculitis)

Is cervical lymphadenopathy present?

(to rule in/out infection)

Is otitis media present?

(to rule in/out upper airway infection)

Is cobblestone appearance present in the upper airway?

(to rule in/out upper airway infection)

Is rales/wheezing present?

(to rule in/out lower airway infection)

Is nasal crease present?

(to rule in/out rhinitis)

Is conjunctivitis present?

(to rule in/out rhinitis)

Are there any ocular and nasal discharge? (to rule in/out
rhinitis)

Are there any congestion?

(to rule in/out both rhinitis & asthma)
Physical Examination
Conscious, coherent, not in respiratory distress
RR=20
T=afebrile
No stunting
No wasting
Pink conjunctivae, anicteric sclerae,
(+) Dennie-Morgan intraorbital folds
(+) Pale, congested turbinates
(-) Nasal discharge
Equal chest expansion, (-) Rales and wheezes
Very dry skin, (+) Erythematous, coalescent papules on the neck,
nape, antecubital areas
(+) Yellowish crust over weeping erythematous base, cheek and
perioral area, popliteal
(+) Lichenified patches on thighs
(+) Palmar hyperlinearity
Page 2 / 3
SGD 2: Rash
(+) Hypopigmented patches on upper extremity
(+) Petechiae, bruising
4.
5.
6.
Question 3: Given the history and physical examination,
what is your diagnosis? And what are your differentials?
Give the basis for each.
general
principles
Anti-Leukotrienes
Patient Education
Avoidance of Allergens
Please see Atopic Dermatitis Trans for specific details and MOA of the
above medications.
PrimaryforDiagnosis
– Atopic Dermatitis with Allergic Rhinitis
each.
Please uestion
see Appendix
for differential
diagnoses
and the
bases for the
1: As part
of your history
taking, what
additional
history
will you elicit?
primary
diagnosis.
Question 4: Discuss the
management for this case
Give the basis for each.
OS 216
END OF TRANS
Mac: Hi.
Thea: Hi PHIve Star, let’s go to the salon! I’m
so missing it na!
of
Larie: AFTG!
for each.
1. Moisturize
uestion 1: As part of your history taking, what additional
2. Anti-Histamines
history will you elicit?
3. Corticosteroids
Appendix
TRANSER, TRANSER, TRANSER
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