case

A 25-year-old woman presents to the emergency department (ED) with a 2-day history of dull left lower quadrant (LLQ) pain and a diffuse pinkish rash. One week ago, she was diagnosed with streptococcal pharyngitis at an urgent care center for students and was discharged with a prescription for amoxicillin. Three days later, she developed the pinkish rash; the rash was diagnosed by a dermatologist to be an allergic reaction to the amoxicillin. The dermatologist prescribed prednisone and discontinued the amoxicillin. The patient subsequently developed nausea, vomiting, fever, and the aforementioned LLQ pain. She denies experiencing any vaginal bleeding or discharge, dysuria, increased urinary urgency or frequency, melena, or hematochezia. She reports feeling weak and dizzy. Other than her visit to the student urgent health care center, she has no past medical history, is not taking any medications, and does not have any allergies. She does occasionally drink alcohol, but she denies smoking tobacco or using illicit drugs. She also denies using tampons. eh2 die nie deny lak..jom team house g check ruma patient nih~

On physical examination, she is noted to be alert and have a normal mental status, but is otherwise pale and ill-appearing. Her blood pressure is 65/35 mm Hg, with a regular heart rate ranging between 110-120 bpm. Her respirations are measured at 20 breaths/min, her oral temperature is 103.46°F (39.70°C), and her oxygen saturation is 93% while breathing room air. The integument examination reveals a diffuse, erythematous, blanching rash; however, the integument is otherwise warm and dry to the touch. The oropharynx is clear, with no exudates or erythema. Diffuse mild crackles are noted in the patient's lungs. She has normal heart sounds, with a regular rhythm and a slightly increased capillary refill. Her abdomen is soft and minimally tender to deep palpation in the LLQ. No abdominal masses or hepatosplenomegaly are appreciated. The pelvic examination reveals no external vaginal or cervical lesions, cervical motion tenderness, or adnexal masses or tenderness. No foreign bodies are visualized.

The laboratory examination, including a complete blood cell (CBC) count and comprehensive metabolic panel, is essentially unremarkable, except for a white blood cell (WBC) count of 31.6 × 103/µL (31.6 × 109/L), band neutrophils of 13% (0.13) and a creatinine of 2.4 mg/dL (212.16 µmol/L). Her arterial blood gas analysis is remarkable for a partial pressure of carbon dioxide (pCO2) of 27 mm Hg (3.59 kPa), a partial pressure of oxygen (pO2) of 56 mm Hg (7.45 kPa), a bicarbonate of 19 mEq/L (19 mmol/L), and a base deficit of 4.4 mmol/L (normal range, 0-2 mmol/L). The urinalysis, cervical Gram stain, and potassium hydroxide (KOH) wet preparation are all normal. A chest radiograph is taken that shows changes consistent with early adult respiratory distress syndrome (ARDS; see Figure 1).

Upon returning from the radiology department, she is noted to again become hypotensive, tachycardic, and tachypneic, as well as remaining febrile despite the administration of acetaminophen. An elective rapid-sequence intubation is performed for the pending respiratory failure. She is diagnosed with septic shock (etiology unknown) and treated empirically with clindamycin, vancomycin, and meropenem. Blood, urine, and respiratory cultures are obtained, and antistreptolysin O (ASO) and toxic shock syndrome toxin–1 (TSST-1) antibody titers are ordered. A lumbar puncture is deferred, and the patient is admitted to the medical intensive care unit (ICU).

p/s : korg bace lah dulu pas2 br check diagnosis korg tuh betol or tak.try2 best tau~


The most likely diagnosis is toxic shock syndrome.

Cause : Enterotoxin from staph aureus or strep pyogenes
Characters : asscociated with wound contaminated by s-aureus,due to contaminated dressing or improper use of synthetic tampon,toxin enter circulation and acts as super antigen
Clinical pictures: fever,headache,vomit,diarrhea,hypotension and shock