Transcript steven-case - KE Official

Stevens-Johnson Syndrome
A Case Presentation
Patient Profile
Name: 王O芬
 Age: 49 years old
 Gender: female
 Marriage: divorced
 Occupation: working in printingrelated factory
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Chief complaint
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Multiple oral ulcers since one week
ago.
Present Illness-1
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This patient is a 49 years old female. She had
low back pain onset since last Monday (11/14) and
went to LMD for help on last Wednesday
morning(11/16). Two kinds of NSAIDs along with
some other medications were prescribed for her.
After taking the medication, she had multiple oral
ulcers onset on 3 P.M.. The ulcer was with sharp
pain and was progressively worsening till this
Wednesday. There was no fever, chills, cough, stiff
nose, nausea, vomiting, diarrhea, tarry stool,
dysuria, nor hematuria ever since the onset of oral
ulcer episode. There was difficulty and discomfort
during swollowing liquid. Such discomfort started
many years ago.
Present Illness-2
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Then on this Monday (11/21) she visited our ENT
for help. Mycostatin, colchicine, and some other
medications were prescribed for her.
She didn’t take the medicine and in turn went to
our ER for feeling great discomfort. A small ulcer
in the vulva was found as well. She denied any
skin rash over trunk or extremities.
At ER, blood routine and CRP were done and the
results were normal. Under the impression of oral
ulcers and suspicious drug-allergy reaction , she
was admitted into our ward for further survey and
treatment.
Past History
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1. Medical history: GERD with
medication control.
2. Surgical history: left
herniarrhaphy in 2008 in our hospital.
3. Depression and other psychiatric
disorders for years and are now being
treated in the LMD with mesyrel,
zompidem, and alpraline.
Personal History
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Allergy: NSAIDs: aceclofenac or ketoprofen.
(Stevens-Johnson Syndrome)
Alcohol: nil.
betelnets: nil.
Smoking: nil.
Special environmental contacts: The patient
works in a factory with high possibilities of
contacting various types of chemical agents,
especially organic-solvants.
Family history: no DM. no hypertension, no
AIR disease
Review of system
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1. General: Weight loss(+) poor
appetite(+), general malaise(+).
2. HEENT: oral ulcer(+), neck mass(+),
dysphagia(+).
3. Respiratory: chest tightness(+).
4. Cardiovascular: Palpitation(+).
5. Gastrointestinal: dysphagia(+).
6. Cutaneous:nail change(+).
Vital sign: BT: 35.8 BP: 134/84 R: 18
P: 84
Physical Examination
1. General appearance: acutely ill
2. Consciousness: clear
3. Peripheral perfusion: Normal
4. Skin : normal
5. HEENT:
Head, Eyes, and Ears: normal
Mouth & Throat: oral ulcers(+)
Neck: one thyroid nodule on the right lobe.
Trachea, carotid artery, and Jugular vein: normal
Thyroid gland : one nodule found in the right lobe region
6. Chest and abdomen, and extremities: normal
7. Nervous system: normal
8. Genitalia area: one shallow ulcer found on the vulva.
Lab findings:
11/21
 T3, TSH, free T4:normal
 ANA, CRP, TPHA: normal
 RF: normal
 Uric Acid: normal
 CBC: normal profile
 Electrolyte: K[3.06 mEq/L]
 IGE: normal
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Lab findings:
11/25:
 R.B.C.[3.60 10^6/uL]
 Hct[33.9 %]
 Na[140.2 mEq/L]
 K[3.60 mEq/L]
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Exam: 11/21
At ENT OPD: Nasopharyngoscopy:
No specific findings beside multiple oral
ulcers.
 In the ER: chest X-ray:
Rt & Lt CP angle blunting, probably
pleural effusion or pleural change.
Bilateral apex pleural thickening
Mild Increased bronchovascular lung
markings of both lungs.
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Exam: 11/23
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EKG: no specific finding
Progress
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1.
2.
3.
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5.
Medication Prescribed by ENT on 11/21:
Colchicine: 1 tab BID for 5 days
Mycostatin: 3 c.c. TID for 5 days
Gascon: 1 tab TID for 5 days
Mopride: 1 tab TID for 5 days
Kolantyl: 1 tab TID for 5 days
Progress
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S: 11/23 oral ulcer with pain, no further worsening.
11/24 oral ulcer with pain, feeling much improved.
O: 11/23~11/24 Consciousness: Normal. Vital signs: normal. PE:
oral ulcer. 1 thyroid mass found in the right lobe region. No
other specific finding.
A: 11/23 Stevens-Johnson Syndrome. Stationary
11/24 Stevens-Johnson Syndrome. Improving
Plan: Medication: Prescribed in our ward on 11/23:
Vitapoly 1 tab QID 11/23~11/25
Panadol 1 tab QID 11/23~11/25
MgO 1 tab BID 11/23~11/25
Periactin 4mg 1 tab TID 11/23
Broen-C 1 Tab QID
Parmason 漱口水 prn, Kenalog 口內膠
Morphine 3mg IM prn for oral ulcer pain control. 11/24~11/25