M.J., a 58 years old female, widowed, from Candaba, Pampanga was admitted for the first time at Jose B.

Lingad Memorial Regional Hospital due to generalized maculopapular rash. Present condition started 2 weeks prior to admission as limitation of motion accompanied by pain to touch, swelling, warmth and redness of the left knee. No skin discoloration and ulcerations observed. No other symptoms noted. Consultation to a primary clinic was done. An initial impression of Acute Gouty arthritis was made. BUA was requested revealing high result (7.5mg/dL). Colchicine 1mg/tab initially followed by 500mcg q2° until relief of pain, vomiting, diarrhea or abdominal pain was given. However, due to persistent abdominal pain, a follow-up was made. Colchicine was replaced with Diclofenac 50mg/tab TID taken for 3 days then BID until acute attack disappears. Symptoms improved. Above medication was continued. 1 week prior to admission, intermittent fever accompanied by body malaise, soreness of throat and burning sensation of both eyes were noted. No blurring of vision and itchiness were experienced. No consultation was done. Paracetamol 500mg/tab, 3x a day was taken. 3 days prior to admission, still with the above condition, patient noted pain upon swallowing of food accompanied by vomiting. Appearance of painful, non-pruritic, erythematous rashes on the face and upper torso were also observed. There were no difficulty in breathing, diarrhea and signs of bleeding. Prompt consultation to our institution was done, hence the admission. Patient is a diagnosed hypertensive for 10 years taking Amlodipine 10mg/tab, O.D. No other medical condition was noted. No history of travel noted. No wadding in floods mentioned. Patient is a housewife with 2 children living in a well lighted, screened windows/doors bungalow type of housing. Potable water source is from NAWASA. There were no history of smoking and alcohol consumption. Diet includes fish, poultry and rice with preference to canned goods, legumes, beans and crustaceans. Review of systems was unremarkable Physical examination was as follows: Vital signs: BP: 160/100 mmHg PR: 110 bpm Temp.: 39°C UO: 40mL/hr BMI: 24 (+) poorly defined, non-pruritic, tender, flat, erythematous macules with darker purpuric centers symmetrically seen on the face and upper trunk and lower extremities (+) tender edematous erythema on both palms and soles (-) discoloration, (-) abscess formation, (-) ulceration

Skin:

smooth edge and palpable 1cm below right costal margin (-) tenderness upon palpation Genitourinary: (-) ulcerations. OD (+) deep hemorrhages. (+) brown stool on examination finger Peripheral vascular: (-) edema. OU (+) A-V tapering at 4:30 o’clock. OU (+) multiple ulcerations with reddish base and irregular borders measuring approximately 5mm distributed on both right and left buccal mucosa (+) <1cm. (-) retraction. PMI at 5th ICS LMCL Normal rhythm with tachycardia. OS (+) punctuate hard exudates. (-) masses Rectal: (-) masses. (-) murmur Abdomen: Flabby.HEENT: VA: 20/20 OU (-) ptosis. (+) erythematous bulbar conjunctiva. liver span 7cm in RMCL. bilaterally Chest/Lungs: Symmetrical chest expansion. 2 disc diameters from the disc. OU (+) yellowish orange optic disc with blurred nasal border cup. OU (-) corneal opacities. (-) calf tenderness Neurologic: unremarkable Stevens-Johnson Syndrome secondary to Diclofenac intake Hypertension Stage II. ulcerations Fundoscopic examination: (+) red reflex. normal bowel sounds. palpable. uncontrolled t/c Asymptomatic Hyperuricemia Admitting Impression: . (-) thrills. OU (+) intact EOM. OU (+) focal narrowing of retinal arteries. (+) tearing. OU (+) direct and consensual papillary reflex to light. (-) lagging Breath sounds vesicular with no added sounds Cardiovascular: Adynamic precordium. tender posterior auricular and submandibular lymph nodes.

venoclysis was started with D5NSS as IV fluids.7mmHg Problem #3: t/c Asymptomatic Hyperuricemia Diagnostic examination: Treatment: serum BUA Dietary restrictions (low purine diet) CBG: 80mg/dL . right deltoid Tetanus toxoid 0. Problem #1: Stevens-Johnson Syndrome secondary to Diclofenac intake Diagnostic examinations: CBC with platelet count Serum Na/K BUN/Crea.1% dental paste: Apply as thin film qHS Benzydamine HCL 15mL to be held in the mouth and swirled around for at least 30sec. CBG was taken then monitored q24°. left deltoid -referral to an ophthalmologist/ENT for co-management -referral to an infectious specialist for co-management Problem #2: Hypertension Stage II. Vital signs were taken and recorded q1°.Upon admission. uncontrolled Diagnostic examinations: Treatment: total lipid profile 12 lead ECG Nicardipine HCL: Initial 5mg/h slowly then may titrate q15’ by 2.5mL IM. u/a SGOT/SGPT PT/PTT Chest X-ray Blood GS/CS x 2 sites and oral GS/CS Treatment: Hydrocortisone 200mg/IV STAT then 100mg/IV q6° Paracetamol 2mL/IV q°4 Diphenhydramine 25mg/IV q4° (for pruritus) Famotidine 20mg/IV q12° Triamcinolone 0.5mg/hr until MAP of 126. at 1-3 hours interval throughout the day May give Tetanus prophylaxis as follows: TIG 250 units IM. Clear liquid diet was started.

56 WBC: 10 x 10 9/L Neutrophils: 0. flat.3% ophthalmic solution: Apply 1-2gtts q4°.Course in the ward: DAY1: S: (-) blurring of vision (+) painful rashes (+) soreness of throat (+) difficulty in swallowing (-) abdominal pain (-) dysuria VS: BP: 140/80mmHg PR: 100bpm T°: 38°C UO: 35mL/hr (+) tearing. OU (+) multiple ulcerations with reddish base and irregular borders measuring approximately 5mm distributed on both right and left buccal mucosa (+) poorly defined.8 sec PTT: 27. (+) erythematous bulbar conjunctiva. uncontrolled t/c Asymptomatic Hyperuricemia continue medications Ophthalmology management: Tobramycin/Dexamethasone 0.64 Lymphocytes: 0.78mmol/L Serum BUN: 8.3mmol/L . erythematous macules with darker purpuric centers symmetrically seen on the face and upper trunk and lower extremities (+) tender edematous erythema on both palms and soles CBG: 90mg/dL Stevens-Johnson Syndrome secondary to Diclofenac intake Hypertension Stage II.4 sec Serum Na: 140mmol/L Serum K: 3. non-pruritic. tender.3 Platelet count: 317 x 10 9/L PT: 12. OU Solcoseryl 5% ointment: Apply TID. OU O: A: P: Laboratory results: CBC with platelet count: Hgb: 142g/l Hct: 0.

Serum Crea: 121.7umol/L Serum SGOT: 121 U/L Serum SGPT: 98 U/L u/a: color: yellow-orange transparency: turbid Sp.10mmol/L HDL: 1.030 Protein: +3 Pus cells: 3-5 Chest X-ray: unremarkable 12 lead ECG: sinus tachycardia DAY2: S: (-) blurring of vision (+) ulcerative lesions on both palms and soles (+) soreness of throat (+) difficulty in swallowing (-) abdominal pain (-) dysuria VS: BP: 130/80mmHg PR: 90bpm T°: 37. Gravity: 1.02mmol/L Triglycerides: 3. forearm and both lower extremities (+) ulceration on both palms and soles Serum BUA: 0.48umol/L Lipid profile: Total cholesterol: 8. controlled Hyperlipidemia continue medications and ophthalmic management Infectious Disease Specialist management: Start Fusidic acid cream 2%: Apply BID Follow-up blood and oral GS/CS O: P: .Johnson syndrome secondary to Diclofenac intake Hypertension Stage II.02mmol/L CBG: 90mg/dL A: Stevens . (+) erythematous bulbar conjunctiva.64mmol/L LDL: 5.5°C UO: 42mL/hr (+) tearing. OU (+) crusted lesions on both buccal mucosa (+) erythematous macules with vesicular lesions on upper trunk.

OU For repeat BUN/Crea. SGOT/SGPT Oral GS/CS: no growth in 3 days of incubation UO: 38mL/hr O: A: P: .1% dental paste: Apply as thin film qHS Benzydamine HCL 15mL to be held in the mouth and swirled around for at least 30sec. OD Triamcinolone 0.DAY3: S: (-) blurring of vision (+) crusted lesions on both lower extremities (+) decrease in soreness of throat (+) intake of liquid to soft diet (-) abdominal pain (-) dysuria VS: BP: 130/80mmHg PR: 85bpm T°: 36. controlled Hyperlipidemia Shift Hydrocortisone to Prednisone taken as follows: Day1: 10mg PO BID (before breakfast and at bedtime) 5mg PO BID (after lunch and dinner) Day2: 5mg PO TID and 10mg PO at bedtime Day3: 5mg PO QID Day4: 5mg PO TID Day5: 5mg PO BID Day6: 5mg PO before breakfast then discontinued Shift Nicardipine drip to Amlodipine 5mg/tab. OU Solcoseryl 5% ointment: Apply TID. (+) decrease in conjunctival erythema. at 1-3 hours interval throughout the day Fusidic acid cream 2%: Apply BID Paracetamol IV was discontinued CBG monitoring discontinued Ophthalmology management: Tobramycin/Dexamethasone 0. OD Shift Famotidine to Omeprazole 20mg/tab.3% ophthalmic solution: Apply 1-2gtts q4°. OU (+) crusted lesions on both buccal mucosa (+) crusted vesicular lesions on both lower extremities (+) ulceration on both palms and soles Stevens-Johnson Syndrome secondary to Diclofenac intake Hypertension Stage II.5°C (+) tearing.

5°C UO: 35mL/hr (-) tearing.8mmol/L Serum Crea: 92mmol/L Serum SGOT: 37 U/L Serum SGPT: 36 U/L O: A: Stevens-Johnson Syndrome secondary to Diclofenac intake Hypertension Stage II.5°C UO: 40mL/hr (+) tearing. controlled Hyperlipidemia continue medications P: DAY5: S: O: A: P: . (+) decrease in conjunctival erythema. OU (+) crusted lesions on both buccal mucosa (+) crusted vesicular lesions on upper trunk and both upper and lower extremities with occasional scab formations (+) increase scab formations on both palms and soles Stevens-Johnson Syndrome secondary to Diclofenac intake Hypertension Stage II. OD (-) blurring of vision (+) crusted lesions on upper trunk. controlled Hyperlipidemia continue medications Start Atorvastatin 80mg/tab. OU (+) crusted lesions on both buccal mucosa (+) crusted vesicular lesions on both upper and lower extremities (+) scab formation on both palms and soles Serum BUN: 4. upper and lower extremities (-) abdominal pain (-) dysuria VS: BP: 120/70mmHg PR: 78bpm T°: 36. (+) decrease in conjunctival erythema.DAY4: S: (-) blurring of vision (+) crusted lesions on both lower extremities (+) decrease in soreness of throat (+) intake of soft diet (-) abdominal pain (-) dysuria VS: BP: 130/70mmHg PR: 80bpm T°: 36.

3% ophthalmic solution and Solcoseryl 5% ointment P: DAY7: S: O: A: P: . upper and lower extremities (-) abdominal pain (-) dysuria VS: BP: 130/70mmHg PR: 75bpm T°: 37°C UO: 38mL/hr (-) tearing. (-) conjunctival erythema. controlled Hyperlipidemia continue medications Discontinue Tobramycin/Dexamethasone 0. OU (+) appearance of epithelialized surface on both buccal mucosa (+) increase in scab formations on the upper trunk and both upper and lower extremities (+) scab formations on both palms and soles Blood GS/CS: no growth in 7 days of incubation on both sites O: A: Stevens-Johnson Syndrome secondary to Diclofenac intake Hypertension Stage II.Johnson syndrome secondary to Diclofenac intake Hypertension Stage II. OU (+) increase appearance of epithelialized surface on both buccal mucosa (+) increase in scab formations on the upper trunk and both upper and lower extremities (+) scab formations on both palms and soles Stevens .DAY6: S: (-) blurring of vision (+) crusted lesions on upper trunk. (-) conjunctival erythema. upper and lower extremities (-) abdominal pain (-) dysuria VS: BP: 130/80mmHg PR: 82bpm T°: 37°C UO: 35mL/hr (-) tearing. controlled Hyperlipidemia continue medications (-) blurring of vision (+) intake of low purine diet (+) scab formations upper trunk.

OD Educating the risks of acquiring Stevens-Johnson syndrome For repeat Serum BUA after 1 week O: A: P: . OU (+) re-epithelialized surface on both buccal mucosa (+) scab formations on the upper trunk and both upper and lower extremities (+) scab formations on both palms and soles Stevens . OD Atorvastatin 80mg/tab.2°C UO: 35mL/hr (-) tearing. improved Hypertension Stage II. controlled Hyperlipidemia May go home Discontinue Fusidic acid cream 2% Home medications: Prednisone 5mg PO before breakfast then discontinued Triamcinolone 0.DAY8: S: (-) blurring of vision (+) intake of low purine diet (+) scab formations upper trunk. upper and lower extremities (-) abdominal pain (-) dysuria VS: BP: 130/870mmHg PR: 72bpm T°: 36.1% dental paste: Apply as thin film qHS x 3 days Benzydamine HCL 15mL x 3 days Amlodipine 5mg/tab.Johnson syndrome secondary to Diclofenac intake. (-) conjunctival erythema.