Free 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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