Case+1

=Case #1 =

This wiki is the being used as a housing location for these case scenarios. Each student is to answer each of the case scenarios and turn in for grading as per the course syllabus.
=== Ms. B. is a 18-year old, white, single female who presents for her three month recare appointment. Upon review of her medical history, Ms. B. discloses she has a sore throat and has had some difficulty swallowing for the last five days. Ms. B. takes phenytoin daily and took it this morning at 8:00 a.m. Her last seizure was eight months ago. Ms. B. also discloses she has been taking acetaminophen 500 mg three times a day for the last five days to address her sore throat that she attributes to being ran down due to “trying to do too much”. ===

=== Your E & I exam reveals creamy white lesions on the tongue. You take gauze square and wipe tongue but the white lesion remains. You also note that her free gingiva is generalized erythemic, swollen, scalloped and smooth. You question Ms. B. as to the occurrence of gingival bleeding and she confirms she has experienced this recently. When questioned on what can cause this, you reply “poor oral hygiene, pregnancy, systemic changes”. Ms. B. states that she is pregnant but has not told her parents yet. ===

**What is your overall impression of this case?**
=== // I  t is possible that the phenytoin she is taking to control her seizures is contributing to her erythemic, swollen and bleeding gingiva. A common problem related to phenytoin therapy is gingival hyperplasia appearing as gingivitis or gum inflammation. However, this is most commonly observed during the first 6 months of therapy; the fact Ms. B has not had a seizure in the last 8 months indicates she has probably been taking the medication for over 6 months. She may either be having an uncommon prolonged reaction to the Phenytoin or the gingival overgrowth and erythemic tissue may be due to pregnancy, such as Pyogenic Granulomas (Pregnancy Tumors). It is not stated when the tissue change occured, so we do not have a baseline to compare it to. The patient indicated that she has had a sore throat for about five days and has taken acetaminophen, 500mg three times per day, for five days and yet she has not experienced any relief. This may indicate that she has an infection that is causing her sore throat. In addition, she stated that she is trying “to do too much,” indicating that she has put herself in stressful situations, and stress inhibits the immune system. Thus, resolution of bacterial or viral infection would be expectedly prolonged. Our differential diagnosis for the milky white lesion on her tongue would include leukoplakia in a high-risk area, due to possible dysplasia or it could be squamous cell carcinoma. Squamous cell carcinoma occurs in young female nonsmokers, especially on the tongue. // ===

**Are there any possible drug interactions? If so, what are they? What would you recommend to the patient to address these?**
=== Yes. Possible drug interactions include that Phenytoin may reduce the effectiveness of acetaminophen. The patient should be referred to her doctor, not only for this interaction but she may need other medications to take care of the swollen throat as there may be an infection and acetaminophen will just control the pain. Her dosage with phenytoin may need to be changed as well. A symptom of higher concentration include drowsiness, lethargy and depression; which could also be due to her preganancy. ===

**Are there concerns with the drugs being taken and Ms. B. pregnancy status? If so, please explain.**
===There is a Pregnancy Risk Factor D contraindication for phenytoin. The benefits and risks must be weighed due to positive evidence of human fetal risk; maternal benefit may outweight fetal risk in serious or life-threatening situations. Additional adverse reactions may include fetal toxicity. Anticonvulsant drug use may contribute to increased incidence of birth defects. Since Ms. B has just recently become pregnant, it is strongly advised that she see her physician as soon as possible. Her physician may want to adjust her medications and may want to educate her on the risk factors of her pregnancy. The concentration dose of phenytoin may also deplete folic acid which would be of concern as it prevents birth defects, so her doctor may prescribe her a prenatal vitamin or folic acid supplement. Phenytoin inhibits the enzyme that actually produces folic acid in the intestines. Therefore, phenytoin indirectly reduces folic acid levels in the body. This can potentially lead to megaloblastic anemia. ===