Free Medical Drug Reaction Design Case Report Template

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Free Medical Drug Reaction Design Case Report Template

Medical Drug Reaction Design Case Report

Sunnydale Hospital
Department of Internal Medicine
Medical Drug Reaction Case Report
Date of Report: November 26, 2055
Report Number: 2050-0098

1. Patient Information

  • Patient ID: 0012456

  • Age: 58

  • Sex: Female

  • Height: 5'4"

  • Weight: 150 lbs

  • Ethnicity: Caucasian

  • Medical History: Hypertension, Type 2 Diabetes, Mild Asthma

  • Allergies: No known drug allergies (NKDA)

2. Medication Information

  1. Drug Name(s): Lisinopril (Brand Name: Prinivil)

  2. Dosage and Administration:

    • Dosage: 10 mg

    • Route of Administration: Oral

    • Frequency: Once daily

    • Start Date: November 1, 2055

    • End Date: November 18, 2055 (Discontinued due to ADR)

  3. Reason for Prescription: Management of Hypertension

3. Description of Adverse Drug Reaction (ADR)

  1. Date/Time of Onset: November 15, 2055 (14 days after starting Lisinopril)

  2. Symptoms/Signs:

    • Swelling in the face, particularly around the lips and tongue

    • Difficulty breathing

    • Rash developed on the arms

    • Elevated blood pressure despite medication

  3. Severity: Severe

  4. Duration: 2 days (Symptoms persisted for 2 days before intervention)

  5. Treatment for ADR:

    • Lisinopril was immediately discontinued

    • The patient was given IV steroids (Hydrocortisone 100 mg) and antihistamines (Diphenhydramine 25 mg)

    • Oxygen therapy administered for respiratory distress

    • Symptoms subsided within 48 hours after treatment initiation

  6. Outcome: Complete recovery with no lasting effects

4. Clinical Assessment

  1. Primary Diagnosis: Angioedema due to Angiotensin-Converting Enzyme (ACE) Inhibitor (Lisinopril)

  2. Differential Diagnosis:

    • Anaphylaxis (ruled out after evaluation of airway and blood pressure)

    • Allergic reaction to a different medication (ruled out)

    • Idiopathic angioedema (ruled out due to recent ACE inhibitor use)

  3. Laboratory and Diagnostic Test Results:

    • CBC: Mild eosinophilia, otherwise normal

    • Serum Electrolytes: Normal

    • Liver Function Tests (LFTs): Normal

    • Renal Function Tests (Creatinine, BUN): Normal

  4. Medical Management:

    • Lisinopril was discontinued

    • Antihistamines and corticosteroids administered for symptom relief

    • Oxygen therapy to manage respiratory distress

    • Follow-up at 48 hours showed full resolution of symptoms

5. Conclusion

  1. Drug Reaction Classification: Type I (Immediate Hypersensitivity Reaction)

  2. Possible Causality: High likelihood that Lisinopril caused the ADR, as symptoms occurred shortly after initiation of the medication

  3. Recommendations for Future Use:

    • Lisinopril should not be prescribed to this patient in the future

    • Consideration of alternative antihypertensive medications (e.g., Calcium Channel Blockers, ARBs)

    • Recommend monitoring for other potential side effects if any new medications are started

  4. Follow-up Plans:

    • A follow-up appointment in 2 weeks for a reassessment of hypertension management

    • Continue monitoring for any delayed reactions or complications

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