3. CASE SUMMARY
A 23 year old female had fever with upper respiratory symptoms from13/1/2020 for which she
was hospitalized elsewhere and medications were given (Gentamicin , piroxicam , roxithromycin ,
cefoperazone sulbactam). Subsequently she developed conjunctival congestion with mucocutaneous
lesions .0n 23/1/2020 she was admitted in our KMCH hospital . TEN vs Autoimmune cause (SLE/Behcets)
was considered . She was started on high dose parenteral steroids . Her autoimmune panel (ANA + ANCA)
were negative. her blood urine & throat swab culture were negative . She was managed with parenteral
dexamethasone with other supportive care. Dermatology skin biopsy results were awaited .
Then further will see into it…….
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4. PATIENT PROFILE :
• IP NO: F40099.
• AGE /SEX : 23YR OLD / FEMALE.
• MARRITAL STATUS : UNMARRIED.
• NATIVE PLACE: SALEM.
• PURSUING STUDY: M.SC. BIOTECH.
• DATE OF ADMISSION: 23/1/2020.
• DATE OF DISCHARGE: 30/1/2020.
• PRIMARY CONSULTANTS: DR.VARUN SUNDARAMOORTHY .
DR. JEEVAN KUMAR (MD) DERMATOLOGIST.
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5. SUBJECTIVE EVIDENCE
• PAST MEDICAL HISTORY: FEVER FROM 13/1/2020.
• TREATED IN MULTIPLE HOSPITALS FROM 18/1/2020.
• PRIMARILY ADMITTED IN MAGIL HOSPITAL ON 18/1/2020.
• DR. J. SHAAMLI M.B.B.S
RX
INJ. GENTALAB - 1
INJ. DOLOFORCE - 1
TAB.ROXID 150 - 6 (1-0-1)
TAB.PARAMET - 6 (1-0-1)
CAP.BENADRYL - 3 (0-0-1)
FEVER PERSISTS NOT CURED.
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Composition of each brand
1) Gentamicin .
2) Piroxicam .
3) Roxithromycin.
4) Paracetamol & metoclopramide.
5) Diphenhydramine.
7. PHARMACIST INTERVENTION
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Sulphur containing drugs and sulpha drugs which contains an SO2 & NH2 group with may cause cytotoxic reaction and toxic
necrolysis such as TEN. Gentamycin sulphate and piroxicam also contains the same sulphur group.
8. 0N 21/1/2020 @12:33PM
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Dr. S.R.K
Betadine gargle 2% solution
Tab. Azee 500mg
Inj. Para
Inj. Emeset
sumo –L 100ml IVF (paracetamol 1000mg/100ml).
Severe reaction of those drugs developed : started from 19/1/2020.
conjunctival congestion.
Pustular skin lesions (erythema).
Oral ulcers/ aphthous ulcers (coated tongue).
Shortness of breath.
Burning micturition.
Supra pubi tenderness.
Purulent genital discharge.
Membranous tonsillitis (exudate on tonsils).
9. OBJECTIVE EVIDENCE
0N 23/1/2020 ADMITTED IN OUR KMCH HOSPITAL
• @ 3:30PM
PRIMARY INVESTIGATION’S WERE DONE .
ON PHYSICAL EXAMINATION:
Conscious , oriented , afebrile.
Purulent conjunctivitis++,coated tongue , skin lesions in face pealing, throat pain
(rt tonsil enlarged), oral ulcers (difficulty in swallowing informed by patient), shortness of
breath, burning micturition.
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23. 23
DATE TIME NS/RL QUANTITY
24/1 2am
5am
10am
8pm
NS
RL
RL
RL
500ml
500ml
500ml
500ml
25/1 12am
7am
DNS
NS
500ml
500ml
26/1 4am
2pm
RL
RL
500ml
500ml
28/1 9am
12:30pm
5pm
11pm
RL
NS
NS
NS
500ml
500ml
500ml
500ml
29/1 11am
4pm
NS
NS
500ml
500ml
RL- provides more stable pH of 6.5 than the normal saline. But it wont stay in body as long as saline solution.
24. Date Intake Output
23/1/2020 IVF -875ml
Oral -100ml
= 975ml Total intake
Urine -350ml
=350ml Total output
24//1/2020 IVF -1750ml
Oral - 750ml
= 2500ml Total intake
Urine -1000ml
=1000ml Total output
25/1/2020 IVF -1125ml
Oral - 950ml
= 2075ml Total intake
Urine – 1750ml
=1750ml Total output
26/1/2020 Total intake =1150 oral Urine – 1800ml
= 1800ml Total output
27/1/2020 IVF - 1000ml
Oral – 1350ml
=2350ml Total intake
Urine - 1850ml
= 1850ml Total output
28/1/2020 IVF – 2000ml
Oral – 1150
= 3150ml Total intake
Urine - 1600ml total output
29/1/2020 IVF – 1000ml
Oral – 1300ml
= 2300ml Total intake
Urine – 1950 ml
Total output =1950 ml.
Positive fluid
balance.
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25. SPECIAL TEST REPORTS:
• PATHOLOGY REPORT:24/1/2020
RBCS: Crowding of rbcs + normocytic
normochromic rbcs to microcytic
hypochromic rbcs elliptocytes+
WBCS: Adequate in no with few reactive
lymphocytes.
HEMOPARASITES: ABSENT.
• SEROLOGY REPORT: 27/1/2020
IgG & IgM– NEGATIVE .
ON 25/1/2020 REPORTS :
• AUTOIMMUNE PANEL: (Serum sample)
• ANA+ANCA WERE NEGATIVE.
• ANTI MPO : -VE(0.0874)
• ANTI PR3 : -VE(3.6368)
• CULTURE TESTS:
Blood, urine, throat swab culture
were NEGATIVE.
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27. 27
A cytotoxic reaction of antibiotics is treated with IV
corticosteroids and antihistamines .
IgE mediated reaction may be?
Hypersentivity to gentamycin and cefaperozone salbactam.
29. GOALS OF TREATMENT
• To improve the quality of life.
• To reduce the serious adverse effects of drugs.
• To prevent further complications.
• To reduce the irritation of eyes and mucocutaneous lesions.
• To prevent further ulceration of lips.
• To reduce the genital irritation.
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34. 34
PHARMACIST INTERVENTION:
There were no serious drug – drug interaction .
By the different route of administration – the interaction of drugs is
been neglected.
The proper absorption of drugs were found .
The systemic administration of dexamethasone is very important
dosage move and its been increased the efficacy of drug than the
adverse effects.
Higher efficacy than side effects is proved.
35. THERAPEUTIC OUTCOME’S OF THERAPY
• The eye compliance is reduced and response to treatment is excellent.
• Skin lesions is been reduced by the ointments .
• IV corticosteroids such as dexamethasone played a great role in therapy , symptoms subsided
very nice.
Discharge plan:
• Oral corticosteroids been prescribed on discharge.
• Further to eradicate the lesions ,patient is been discharged with bodily oinment cream and oral
cavity applications .
• To reduce allergy response antihistamine drugs is prescribed.
• To reduce hypersensitive reaction of lungs: cough syrup is given.
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36. DISCHARGE SUMMARY
Medicine Dosage Morning Afternoon Evening Night A/B Food Duration
Tab. Omnacortil 30mg 1 0 0 0 AF 1week
Tab. Nexpro RD 20mg 1 0 0 0 AF 1week
Tab. Tayo - 1 0 0 0 AF 1week
Tab. Bilagra 20mg 0 0 0 1 AF 1week
Syp. Chericof LS 2tsp 2tsp 0 2tsp - 1bottle
Quadrajel &
TESS
FOR LOCAL APPLICATIO
N
Clonate F cream FOR LOCAL APPLICATIO
N
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Patient discharged with hemodynamically stable in condition , tolerating oral feeds well and normal diet is encourag
After 1 week review with CBC ,cr,
37. PHARMACIST INTERVENTION
• In discharge – Tab.Nexpro RD – after food .
• It should be prescribed before food . its efficacy rate is higher and long lasting
when taken atleast 1 hr before food.
PATIENT COUNSELLING:
• Further to any illness- need to inform about her sulphur drug reaction and allergic
conditions to physician’s.
• Normal diet with proper intake of foods ,such as green leafy veggie etcc…,
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