FINAL EVALUATION

DEPARTMENT OF PEDIATRICS AND CHILD HEALTH

FACULTY OF MEDICINE DIPONEGORO UNIVERSITY/
DR KARIADI GENERAL HOSPITAL SEMARANG 2020

Name of participant : Erna Mirani, MD

Date of examination : March 13th 2020

I . PATIENT IDENTITY
Name : JAI Father’s name : Mr. T
Age : 1 years 1 months old Age : 41 y.o
Date of birth : January 27th, 2019 Occupation : security
Sex : Female Education : Senior high school
MR/Reg number : C7523XX/10774XXX Mother’s name : Mrs. A
Date of admission : March 11th, 2020 Age : 36 y.o
Ward : Pediatric Occupation : housewife
Education : Senior high school

II. ANAMNESIS
History taking was done on the 3 rdday of admission (March 13th, 2020, at 3 p.m)
at pediatric ward from patient’s mother and data was obtained from medical record.
1. Present illness:
Chief complaint: reddish patches on all over the body
Patient was diagnosed with general epilepsy since March 2019, had reguler check up
at neurology clinic in tertiary hospital, given valproic acid, vitamin B6, and
levetiracetam, which were taken regularly.
Three weeks prior to admission patient had regular check up, she had no fever,
cough, cold, nausea or vomiting, but she was still noted with seizure regardless the
medication taken, hence lamotrigine was added. After lamotrigine was taken, the
mother complained of subfebrile fever on the child, but the temperature wasn’t
measured.
Two weeks prior to admission the child had fever, the fever was high fever, with
temperature 40oC. There was productive cough and cold at that time. There was no

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nausea or vomitting, the appetite was decrease, the child didn’t want to eat and drink
as much as before, the child still crying adequately, and has normal micturition.
Because of the high fever, the child was brought to primary hospital and got
hospitalized for one weeks. At the hospital the child was given infusion and injection
of ceftriaxone. Then, the child was permitted to be dicharged with some drugs to be
taken home, paracetamol syrup and vitamin.
Four days prior to admission the child had fever again. Fever went up and down.
The fever was high fever, the axillary temperature was 38-39. The child was given
paracetamol, the fever was better with paracetamol but the fever reappeared shortly
afterwards. There was no nausea or vomiting, no cough or cold, no fussy when
urinating, no inflammation on the skin.
Three days prior to admission the child had reddish patches on the skin, the patches
appeared starting from back of the ear, the patches was irregular with different size
and had the same height as the surrounding skin, the child looked itchy, often
scratching her ear, and then the redness spreaded to her chin and lower part of the
cheeks. The child had no story of vacation or contact with insect.
Two days prior to admission some of the patches became purple and spreaded to all
of her face, chest, stomach, and back, the patches still had the same height as the
surrounding skin, and the fever still existed.
One day before admission the patches spreaded to her hand and foot, vesicles began
to appear, some of the vesicles were rupture and form some wound with reddish base.
The child still had fever, and became more often to scratch her body. The child had
productive cough and cold with clear production of nasal mucus. The parents brought
the child to tertiary hospital.
On arrival to Tertiary Hospital Emergency Room, she was alert, active and her
vital signs were : heart rate (HR) 98 bpm, respiratory rate (RR) 22 breaths/min,
axillary temperature was 38.3oC. Physical examination revealed conjungtivitis on her
eyes, macular erythema papules on all of the body, with vesicles and some of the
vesicles had become reddish wound, some of the skin also flaked off. The child has
seizure once at emergency room, seizure on all of her body for about 30 seconds, the
seizure stopped by itself without drugs. Laboratory investigation revealed Hb 11.5
g/dL, Ht 36.7 %, red blood count 4.87 x 10 6/uL, MCH 23.7pg, MCV 75.5 fL, MCHC
31.3 d/dL, white blood count 22.4 x 103/uL, platelet 531 x 103/uL, RDW 21.2%, blood
glucose 80 mg/dL, ureum 41 mg/dL, creatinine 0.6 mg/dL, calcium 2.1 mmol/L,

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sodium 137 mmol/L, potassium 4.5 mmol/L, and chloride 95 mmol/L; eosinophils
0%, basophils 0%, neutrophils stab 2%, neutrophils segment 48%, lymphocytes 39%,
monocytes 9%. Peripheral blood smear showed vacuolization of leukocytes. The
wound was swabed for examination of smear and culture but still waiting for the
result. She was assessed with suspect of drug eruption with differential diagnosis of
Steven Johnson Syndrome and general epilepsy. The patient received IVFD D51/2NS
10 ml/hour, paracetamol syrup 70 mg every 4-6 hours when the temperature was
above 38oC, valproic acid 1.8ml every 8 hours, levetiracetam ½ tablet every 12 hours,
and the lamotrigine was stopped. The child was consulted to dermatovenerology
division, diagnosed with Steven Johnson Syndrome and suggested to give CTM ½
tablet every 12 hours, soft u derm lotion every 12 hours, and mometasone cream every
12 hours on the reddish lesion. The child also consulted to ophthalmology division,
diagnosed with conjungtivitis with differential diagnosis of drug eruption and
suggested to give cendo lyteers eye drop 1 drops every hour, eye hygiene, and to have
evalution after 3 days.
On the first day of admission. The patient was stable, her general condition was the
same as before. She was alert, his vital signs showed HR 108 beats/min, RR 24
breaths/min, axillary temperature 36.7oC. She was assessed with Steven Johnson
Syndrome with differential diagnosis of toxic epidermal necrolysis, general epilepsy
mild malnutrition, and microcephaly. She was given 1 liter of nasal canule oxygen,
IVFD D51/2NS 20 ml/hour, intravenous methylprednisolone 15 mg/8 hours, peroral
paracetamol 70 mg/4-6 hours if the temperature was above 38 oC, peroral valproic acid
1.8ml every 8 hours, levetiracetam 125 mg every 12 hours, and vitamin B6 10 mg
every 8 hours. The child was given fucidic acid ointment for her skin and cendo
lyteers eye drop for her eyes. The child was programmed to have phenytoin injection
if seizures occurred and diet of oral nutritional suplements 60ml ever 4 hours.
On the second day of admission, new vesicles were appeared but the patches was
still the same as before, breastfeeding adequately but still doesn’t want to eat or drink
other than breastmilk. Se was alert and active, his vital signs showed HR 120
beats/min, RR 24 breaths/min, axillary temperature 37.0oC. Wound swab smear
revealed that there was no bacteria or yeast cell. The oxygen was stopped and the child
was programmed to get naso-gastric tube application because the child had low intake.
On the third day of admission (when the patient was selected as final
examination)

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 There is no fever, but the child still has productive cough and cold. The patches and
vesicles was not increasing, still the same as before, some crust appeared. The child
vomit one times, for about 10cc with some mucus. The frequency of scratching has
reduced and the child can sleep well. There is no seizure, the last seizure was at
emergency room.

2. Past medical history

− The child was diagnosed with general epilepsy from 2 months old and routinely
controls at tertiary hospital. The child routinely consume carbamazepine, but had
drug allergy, then the carbamazepine was switched to valproic acid and vitamin B6.
At January 2020 the anti epilepsy drug was added with levetiracetam. At February
19th 2020 the anti epilepsy drug was added again with lamotrigine.
− At April 2020, the child had drug allergy from carbamazepine, appeared redness on
the skin with no vesicles, controlled to dermatovenerologist and was not
hospitalized.
− There was no history of food allergy.

3. Family medical history

− Her sister had rhinitis allergy.
− There was no history of drug allergy from her family.
− There was no history of seizure from her family.

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Pedigree

Figure 1. Pedigree

4. Personal and social history

a. Pre-natal history
The girl was born from 35 years old G4P3A0 mother with full-term pregnancy. She
had routine antenatal care with midwife for >4x during pregnancy. She consumed
daily vitamins regullary. No history of fever, rash, pain or edema, and other illness
during pregnancy and she had normal blood pressure. No history of antenatal
bleeding.
b. Natal history
The boy was born by section caesaria at primary hospital upon indication of being
sterile, assisted by doctor. The baby cried immediately after birth, no cyanosis, no
jaundice, no sign of respiratory distress. The birthweight was 3200 gram, the
birthlength was 47 cm, head circumference was 31 cm.
c. Post natal history
The girl was able to suck breastmilk vigorously. No history of jaundice, edema, or
bleeding event was reported. The child had seizure at 2 months old and diagnosed
with epilepsy, routinely controls at tertiary hospital and routinely consumes anti
epileptic drugs.

Table 1. Perinatal history of sibling and patient

Delivery History
Current
No (body weight/birth condition/delivery Age
condition
assistant)

Aterm, born spontaneously assisted by midwife, 15 y.o Healthy

1. F cry immediately after birth, birth weight 3100 g

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 Aterm, born spontaneously assisted by midwife, 13 y.o Has rhinitis
2. F cry immediately after birth, birth weight 3200 g allergy

Aterm, born spontaneously assisted by midwife, 3.5 y.o Healthy

3. F cry immediately after birth, birth weight 2900 g

4. Aterm, born by section caesaria assisted by 1 y.o Hospitalized

F doctor, cry immediately after birth, birth weight
3200 g

5. History of nutrition
⁻ 0 – 6 months : breast milk on demand
⁻ 6 months – now : breast milk on demand, fortified infant foods, formula milk,
sometimes wasn’t consumed completely. Sometimes the mother give rice porridge
with mashed meat.
Impression: exclusive breast feeding, inadequate in quality and quantity of intake

DAY 1 DAY 2 DAY 3

Type Calories Type Calories Type Calories
Formula 40cc 40 kcal 40cc 40 kcal 30cc 30 kcal
milk
60cc 60 kcal 40cc 40 kcal 40cc 40 kcal

40cc 40 kcal 50cc 50 kcal 30cc 30 kcal

50cc 50 kcal 40cc 40 kcal 40cc 40 kcal

40cc 40 kcal 50cc 50 kcal 40cc 40 kcal

Fortified 3 spoon 135 kcal 2 spoon 90 kcal 2 spoon 90 kcal

infant
food
Total 365 kcal + 310 kcal + 270 kcal +
breastmilk breastmilk breastmilk
Interpretation: Inadequate quantity and quality

6. Growth and development history

Growth
- Birthweight was 3200 gram, length of birth was 47 cm
- Present length is 72 cm, weight 6.58 kilogram, head circumference 42.5 cm, mid
upper arm circumference 11.7 cm, ideal body weight 8.8 kilogram.
- WAZ : -2.91 SD
- HAZ : -1.43 SD

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 - WHZ : -3.07 SD
- HC : -2.05 SD
- MUAC : -2.45 SD
Impression: severely malnourished, very low body weight, normal stature,
microcephaly

Development:
Milestones
The child is 1 year 2 months old.
Personal social : she can drink from cup by herself
Fine motor adaptive : she can scribbles
Language : she can call her mother spesifically
Gross motor : she can’t standing by herself for 2 seconds, she can get to sitting position

⁻ Denver II Test
o Personal social : according to age
o Fine motor adaptive : according to age
o Language : according to age
o Gross motor : according to 10 months old
Impression: gross motor delayed

7. Immunization history
⁻ BCG : 1 time, 1 month (scar +)
⁻ Hepatitis B : 1 times (0 months old)
⁻ Polio : 1 times (0 months old)
Impression : not complete basic immunization, booster (-)

8. History of child’s basic needs

Caring
- Breast milk was given adequately.
- Basic immunization only achieved when the child was born and when the child 1
months old, after the child diagnosed with epilepsy, immunization was not given.
- Health care was achieved from doctors at primary health care and hospital

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 - The child lives with her parents and sisters.
Loving
⁻ She is the fourth child of her family, and was conceived from a happy
marriage.
⁻ She was loved and supported by mother and father.
Stimulation
⁻ She received sufficient stimulation from mother, father, and sisters.

9. Socio-economic condition of the family

Her father worked as a security and mother as a housewife. Monthly household
income is Rp 2.500.000. Medical and hospital cost iscovered by national insurance.
The family is categorized as low socioeconomic family according to the criteria of
Central Bureau of Statistics.
Impression: low socioeconomic status.
Environment:
The child lives with parents, brothers and sister in self-owned permanent house, size
about a ± 8 x 7 m2, with tile roof, ceramic floor, and stone wall. Consist of 3
bedrooms, living room, kitchen, and toilet. There were 1 doors and 3 windows
allowed the sun rays go through the windows. The electricity source is from
National Electricity Company. The water source for washing and bathing is from
Local Water Company. The water source for drinking is from arthetis wells that is
boiled. The wastewater is drained to the ditch, the garbage is taken by garbage
officer regularly. Garbage is collected on the trashbin in front of their house. The
house has good natural light and ventilation. The distance to the primary public
health is 500 meter and to the regional hospital is around 20 km.

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9
 Figure 1. House sketch

II. PHYSICAL EXAMINATION

(Physical examination was performed at Pediatric Ward Dr. Kariadi General Hospital on
March 13th 2020).
General condition : alert, active
Vital signs :Heart rate : 108 bpm
Pulse : regular, adequate volume and pressure
Respiratory rate : 24 breaths/min
Temperature : 36.5o C (axillary)
Oxygen saturation : 97%
Skin : light brown, there are erythematous maculopapular rashes and bullae
Head : Head circumference 42.5 cm, microcephaly
Hair : black color, no alopecia, no squama, not easy to sort
Face : no dysmorphic features
Eye : no pale conjuctiva, no icteric, no sunken eyes, there is purulent
discharge on both eyes
Pupil : isochoric pupil with Ø3 mm/Ø3 mm, normal light and corneal reflexes
Ears : no discharge, no retroauricle lymphadenopathy, no tragus pain there are
erythematous maculopapular rashes
Nose : no nasal flaring, no discharge
Oral
Lips : hyperemis, there is red papules on the angulus labia, no dryness, no
pallor, no cyanosis
Mucosa : there was ulcer, no dryness, no white patch
Tongue : no papillary atrophy, no white patch, no glositis
Throat : tonsil: T1-T1 no hyperemia, nodetritus, no wide crypt, uvula at midline,
there is white patches on palatum durum
Pharynx : no mucosal hyperemia
Neck : symmetry, no lymphadenopathy
Axillary : no lymphadenopathy, there are erythematous maculopapular rashes and
vesicles
Chest : there are erythematous maculopapular rashes and vesicles

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Lung
Inspection : normal chest shape, symmetrical chest expansion, no prominent ribs, no
chest retraction.
Palpation : stem fremitus right = left
Percussion : resonant in all lung field
Auscultation : vesicular breath sound (+) normal; no additional sound: wheezing (-),
ronchi (-)
Heart
Inspection : ictus cordis not visible
Palpation : ictus cordis palpable on left midclavicular line SIC IV, no thrills nor
heaves palpated
Percussion : difficult to determine
Auscultation : heart sound I and II normal, no murmur, no gallop

Abdomen
Inspection : there are erythematous maculopapular rashes and vesicles, no
abdominal distention, no venectation, no umbilical hernia (-)
Auscultation :normal bowel sound
Percussion : tympanic, no shifting dullness, no costovertebral angletenderness
Palpation : no tenderness, kidney ballotement difficult to determine, liver and
spleen are not palpable
Inguinal : no lymph node enlargement
Genital : female, hyperemic OUE (-), there are vesicles
Limbs Upper Lower
Edema pittting -/- -/-
Cyanosis -/- -/-
Erythematous macula +/+ +/+
Vesicles +/+ +/+
Papules +/+ +/+
Movement symmetrical
Tonus normotonus
Muscle Strength 555 / 555 555/555
Pallor -/- -/-
Physiologic reflex +/+ +/+

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 Pathologic reflex -/- -/-
Cranial nerve examination : normal findings
Percentage of burns : 70%

Figure 3. Percentage of burns

Anthropometry status
The child is 1 years and 1 months old girl, birthweight: 3200 gram
Bodyweight : 6.58 kg
Bodyweight last month : 6.8 kg
Ideal bodyweight : 8.8 kg
Head circumference : 42.5 cm
Length : 72 cm
MUAC : 11.7 cm
WAZ : -2.91 SD
HAZ : -1.43 SD
WHZ : -3.07 SD
HC : -2.05 SD
MUAC : -2.45 SD
Impression:
Cross sectional : severely malnourished, very low body weight, normal stature,
microcephaly
Longitudinal : growth faltering

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 IV. LABORATORY AND IMAGING EXAMINATION

Hematology Reference March 10th, 2020 March 18th, 2020

Hb (gr/dL) 10.8– 12.8 11.5 10.7

Ht (%) 35-47 36.7 35.4
RBC (106/uL) 3.9– 5.6 4.86 4.72
MCH ( pg) 23.00 – 31.00 23.7 22.7
MCV (fL) 77 – 101 75.5 75
MCHC (g/dl) 29.00 – 36.00 31.3 30.2
WBC (103/uL) 6 – 17 22.4 16.8
3
Platelet (10 /uL) 150 – 400 531 500
RDW (%) 11.60 – 14.80 21.1 20.2
MPV (fl) 4.00 – 11.0 9 9.5
Impression: leukocytosis, thrombocytosis Anemia

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 hypocromic
microscytic

Clinical chemistry Referenc March 10th , 2020

e
Blood glucose (mg/dl) 80-160 80
Ureum (mg/dL) 15-39 41
Creatinine (mg/dL) 0.60-1.30 0.6
Electrolyte
Sodium (mmol/L) 136-145 137
Potassium (mmol/L) 3.5-5.1 4.5
Chloride (mmol/L) 98-107 95
Calcium (mmol/L) 2.12-2.52 2.1
Impression: Within normal limit

Hematology Reference March 10th , 2020 March 18th, 2020

Eosinophil 2-5% 0 2
Basophil 0-0% 0 0
Band 2-5% 2 0
Segment 20-40% 48 53
Lymphosit 46-76% 39 31
Monocyt 5-15% 9 13
Miscellaneous Myelocytes 1% Metamyelocytes 1%
Metamyelocytes 1%
Erythrocyte Mild anisocytosis (Microcyte), Mild Mild anisocytosis
s poikilocytosis (Microcyte), Mild
poikilocytosis
Platelet Estimated count increase, normal shape Estimated count
increase, normal
shape
Leucocytes Estimated count increase, neutrophil Estimated count
vacuolization, atyphical lymphocyte, increase,
neutrophilia + monocytosis +
Impression Shift to the left, bacterial infection

Culture Date Result

Blood March,10th 2020 sterile

Wound swab smear (11/3/2020)

Gram : there is no bacteria found
Fungi : yeast cell negative

IV. RESUME

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 A 1 years 1 months old girl came with complaint of reddish patches on all over the
body. From the anamnesis, three weeks prior to admission the child had regular check up
because of her epilepsy and she was still noted with seizure regardless the medication
taken, hence lamotrigine was added. After lamotrigine was taken, the mother complained
of subfebrile fever on the child, but the temperature wasn’t measured. Two weeks prior to
admission the child had high fever, cough and cold, the the child was hospitalized for 1
week at local hospital. There was no patches at that time. Four days prior to admission rhe
child had fever again and some reddish patches on the skin, starting form the back of the
ear and spreaded to her chin and lower part of the cheecks. The child often scratching her
body. The day after, the patches started to become purple and vesicles were appeared, there
was ulcer on her lips, too. The patches and vesicles spreaded to her back, stomach, and
then to her hand, leg and foot. There was cough and cold. The child was brought to tertiary
hospital. The child had history of drug allergy (carabamazepine) and her sister had history
of rhinitis allergy.
On arrival to Tertiary Hospital Emergency Room, she was alert, active and her vital
signs were : heart rate (HR) 98 bpm, respiratory rate (RR) 22 breaths/min, axillary
temperature was 38.3oC. Physical examination revealed conjungtivitis on her eyes, macular
erythema papules on all of the body, with vesicles and some of the vesicles had become
reddish wound, some of the skin also flaked off. The child has seizure once at emergency
room, seizure on all of her body for about 30 seconds, the seizure stopped by itself without
drugs. Laboratory investigation revealed an increase on white blood count and platelet,
shift to the left on her differential count.
The patient received IVFD D51/2NS 10 ml/hour, paracetamol syrup 70 mg every
4-6 hours when the temperature was above 38oC, valproic acid 1.8ml every 8 hours,
levetiracetam ½ tablet every 12 hours, and the lamotrigine was stopped. The child was
consulted to dermatovenerology division, diagnosed with Steven Johnson Syndrome and
suggested to give CTM ½ tablet every 12 hours, soft u derm lotion every 12 hours, and
mometasone cream every 12 hours on the reddish lesion. The child also consulted to
ophthalmology division, diagnosed with conjungtivitis with differential diagnosis of drug
eruption and suggested to give cendo lyteers eye drop 1 drops every hour, eye hygiene, and
to have evalution after 3 days.
During hospitalization on tertiary hospital. The patient was stable, his general
condition had improved. There is no fever, but the child still has productive cough and

16
cold. The patches and vesicles was not increasing, still the same as before, some crust
appeared. The child vomit one times, for about 10cc with some mucus. The frequency of
scratching has reduced and the child can sleep well. There is no seizure, the last seizure
was at emergency room. Wound swab smear revealed that there was no bacteria or yeast
cell.

V. DIFFERENTIAL DIAGNOSIS

1. Steven Johnson Syndrome dd/ Toxic epidermal necrolysis

2. General epilepsy on therapy
3. Leucocytosis and thrombocytosis dd/ inflammation, infection
4. Gross motor delay
5. Severely malnourished, very low body weight, normal stature, microcephaly

VI. WORKING DIAGNOSIS

1. Main diagnosis : Steven Johnson Syndrome (L51.1)
2. Comorbids : General epilepsy on therapy (G40.309)
Leucocytosis (D72.829)
Thrombocytosis (D47.3)
Gross motor delay (F82)
3. Complication :-
4. Nutritional status : Severely malnourished (E43)
Very low body weight (R63.6)
Normal stature
Microcephaly (Q02)

VII. PROBLEMS

1. Problems on diagnosis
- Gold standard for diagnosing Steven Johnson Syndrome is biopsy
2. Problems on management
- Management of Steven Johnson Syndome

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 - Good thermoregulation management
- Eye and wound care
- Nutritional care to maintain the nutritional status
- Fluid balance and diuresis
3. Problems on preventive
- Prevent secondary infection by doing hand hygiene
- Prevent the complication of Steven Johnson Syndrome
- Prevent the recurrence of Steven Johnson Syndrome or other drug allergy
- Prevent the recurrence of seizure
4. Problems on monitoring
- Monitoring patient’s symptoms like fever and seizure
- Monitoring wound progression
- Monitoring of fluid balance and diuresis
- Monitoring the treatment response
- Monitoring of nutritional and developmental status
5. Problems on prognosis
- Steven Johnson Syndrome can be recurrent
- Epilepsi?
6. Problems on family psychology
- The psychological burden of the family is related to the current disease of the child
- Stimulation should be provided by the parents
- Fulfillment of caring, loving, and stimulation needs of the patient

VIII. MANAGEMENT PLAN

1. Emergency management:
When the patient was pointed as case, no emergency state was found
2. Diagnostic investigation: wound swab culture
3. Medical therapy :
⁻ IVFD D51/2NS 360/15 ml/hour
⁻ Injection: - Methylprednisolone 15 mg/24 hours (day-4) ~ 2mg/kgBW/day
- Per Oral: - Paracetamol 70 mg/4-6 hours
- Valproic acid 1.8ml/8 hours (40mg/kgBW/day)
- Levetiracetam 125 mg – 0 – 125 mg (35mg/kgBW/day)

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 - Vitamin B6 10 mg/8 hours
- Chlorpheniramine maleat ½ tab/12 hours
- Topical : - Soft u derm cream/12 hours
- Mometasone cream/12 hours
- Fucidic acid cream/12 hours
- Cendo lyteers eye drop for both eye 1 drop every hour
5. Pediatric nutrition care :
Girl, 1 years 1 months, BW: 6.58 kg, ideal body weight : 8.8 kg, Length: 72 cm, mid
upper arm circumference: 11.7 cm
Nutritional management with 5 steps of pediatric nutrition care (PNC) :
Assesment: WAZ : -2.91 SD (low birth weight), WHZ : -3.07 SD (severely
malnourished), HAZ: -1.43 SD (normal stature), HC : -2.05 SD, MUAC : -2.45 SD
1. Impression: severely malnourished, low birth weight, normal stature
2. Nutritional requirements: Calories 100 kcal/kgbw/day, protein 1.23
gram/kgbw/day.
Total calories: 880 kcal/day, protein: 10.8 gr/day, fluid (darrow): 880 ml/day
3. Route of administration: enteral by NGT
4. Formula : oral nutritional suplements 6 x 80 ml, breastmilk
Total calories : 541.2 kkal/day (61.5%), protein 13.92 gr/day (128%)
5. Monitoring: acceptability, tolerance, effectivity (weight gain)
6. Nursing plan :
⁻ Preventing infection with universal precautions (5 moments of washing hand)
⁻ Preventing infection with oral hygiene
⁻ Providing information on patient’s illness and conditions
⁻ Performing pain evaluation
⁻ Keep the room clean, create comfortable ambience to patient
7. Monitoring plan
⁻ Monitoring on wound progression
⁻ Monitoring on fluid balance and diuresis
⁻ Monitoring on dehydration signs
⁻ Monitoring on diet acceptability, tolerance, weight gain, growth
⁻ Evaluation of infection signs
8. Communication, information and education plan

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⁻ Providing information about the disease and diagnostic procedures
⁻ Providing information about the clinical importance of maintaining fluid balance
and diuresis
⁻ Call the nurse or doctor in charge if there is any emergency or deterioration of
patient condition, for example: seizure, fever, and other complaints.
⁻ Providing education and information to keep the environment clean and routinely
practicing five moments of hand-hygiene
⁻ Providing information about the importance of oral hygiene
⁻ Providing information about the patient's prognosis

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 IX. FOLLOW UP

Day of Admission Follow up day 1 (Admission day 3) Follow up day 2 (Admission day 4)
(13/03/2020) (14/02/2020)
Time 16.00 AM 06.00 AM
Fever (-), new vesicle (-), intake via NGT, Fever (-), new vesicle (-), intake via NGT,
Subjective cough (+) cough (+), seizure (-), defecation 3 times/
day
General Alert, active Alert, active
Vital signs HR 125 bpm, RR 24 times/mins, t 37.30C HR 125 bpm, RR 24 times/mins, t 37.30C
P : regular, adequate volume/pressure P : regular, adequate volume/pressure

BW : 6.58 kg BW : 6,58 kg
Physical Face : Erythematous macule (+/+), papula Face : Erythematous macule (+/+), papula
examination (+), vesicle (+) (+), vesicle (+)
Eyes: Secret (+/+). Conjunctiva injection +/-, Eyes: Secret (+/+). Conjunctiva injection +/-,
papule +, erythema + papule +, erythema +
Nose : Nose flaring (-), crustae (+) Nose : Nose flaring (-), crustae (+)
Chest : symmetry, subcostal and intercostal Chest : symmetry, subcostal and intercostal
retraction (-),: Erythematous macule (+/+), retraction (-),: Erythematous macule (+/+),
papula (+), vesicle (+) papula (+), vesicle (+)
Objectives

Cor : Heart sound s1-s2 N, murmur (-)
Lung : vesicular breath sound (+)/(+), ronchi
(+/+), wheezing (-/-)
Abdomen : : Erythematous macule (+/+),
papula (+), vesicle (+) bowel sound (+) N, ,
liver and spleen not palpable
Genitalia : : Erythematous macule (+/+),
papula (+), vesicle (+)
Extremities : edema -/- -/-
Additional Hb 11.5 Ht 36,7 Leucocyt 22400 Platelet
examination 531000 Ureum 41 Creatinin 0.6 Calsium 2.1
Sodium 137 Potassium 4.5 Chlorida 95
E0 Ba0 Stab2 Seg48 Lymphocyt 39 Monocyt
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Assesment  Steven Johnson Syndrome dd TEN
 General epilepsy
 Microsephal, short stature, wasted
Plan
Cor : Heart sound s1-s2 N, murmur (-)
Lung : vesicular breath sound (+)/(+), ronchi
(+/+), wheezing (-/-)
Abdomen : : Erythematous macule (+/+),
papula (+), vesicle (+) bowel sound (+) N,
liver and spleen not palpable
Genitalia : : Erythematous macule (+/+),
papula (+), vesicle (+)
Extremities : edema -/- -/-
Fluid balance: +72 ml/24 hour
diuresis 4,57 ml/kgBW/hour
 Steven Johnson Syndrome dd TEN
 General epilepsy
 Microsephal, short stature, wasted

Medical  IVFD D5 ½ NS 360/ 15ml/hour  IVFD D5 ½ NS 240/ 10ml/hour

therapy  Methylprednisolone IV 15 mg/24 hours  Methylprednisolone IV 15 mg/24 hours
(2mg/kg/day) (day-4) (2mg/kg/day) (day-5)
 Paracetamol oral 70 mg/4-6 hours  Paracetamol oral 70 mg/4-6 hours
 Valproat acid 1.8 ml/8 hours  Valproat acid 1.8 ml/8 hours
(40mg/kg/day) (40mg/kg/day)
 Levetiracetam oral 125mg-0-125mg  Levetiracetam oral 125mg-0-125mg
(35mg/kg/day) (35mg/kg/day)
 Piridoxin oral 10mg/8 hours  Piridoxin oral 10mg/8 hours
 Fusidic acid topical/8 hours  Fusidic acid topical/8 hours
 Mumetason topical cream/ 12 hours  Mumetason topical cream/ 12 hours
 Urea cream / 12 hour  Urea cream / 12 hour
 Lyteers eye drop  Lyteers eye drop
Nutrition ONS 80 ml 6 times a day. ONS 100 ml 6 times a day.

21
 Programme - Fluid balance and diuresis/12 hours - Fluid balance and diuresis/12 hours
- Wait for blood culture result (10/3/2020) - Wait for blood culture result (10/3/2020)
- Physioterapy - Physioterapy

Day of Admission Follow up day 3 (Admission day 5) Follow up day 4 (Admission day 6)
(15/03/2020) (16/03/2020)
Time 06.00 AM 06.00 AM
Fever (-), vomiting (-), new vesicle (-), Fever (-), vomiting (-), new vesicle (-),
crustae (+), cough (+), seizure (+) at 7 pm, crustae (+), cough (+), seizure (+) at 7 pm, 5
Subjective
30seconds, before and after seizure alert (+) seconds, before and after seizure alert (+),
intake direct breast feeding, NGT
General Alert, active Alert, active
Vital signs HR 120 bpm, RR 23 times/mins, t 36.80C HR 128 bpm, RR 23 times/mins, t 36.80C
P : regular, adequate volume/pressure P : regular, adequate volume/pressure

BW : 6,58 kg BW : 6.53 kg
Physical Face : Erythematous macule (+/+), papula Face : Erythematous macule (-/-), papula (-),
examination (+), vesicle (+) vesicle (-)
Eyes: Secret (+/+). Conjunctiva injection +/-, Eyes: Secret (+/+). Conjunctiva injection +/-,
papule +, erythema + papule -, erythema -
Nose : Nose flaring (-), crustae (+) Nose : Nose flaring (-), crustae (+)
Chest : symmetry, subcostal and intercostal Chest : symmetry, subcostal and intercostal
Objectives

retraction (-),: Erythematous macule (+/+),
papula (+), vesicle (+)
Cor : Heart sound s1-s2 N, murmur (-)
Lung : vesicular breath sound (+)/(+), ronchi
(+/+), wheezing (-/-)
Abdomen : : Erythematous macule (+/+),
papula (+), vesicle (+) bowel sound (+) N,
liver and spleen not palpable
Genitalia : : Erythematous macule (+/+),
papula (+), vesicle (+)
Extremities : edema -/- -/-
Fluid balance: +70,25 ml/24 hour
diuresis 5.2 ml/kgBW/hour
Additional Blood culture steril
examination
Assesment  Steven Johnson Syndrome dd TEN
 General epilepsy
 Microsephal, short stature, wasted
Medical  IVFD D5 ½ NS 240/ 10ml/hour
therapy  Methylprednisolone IV 15 mg/24 hours
(2mg/kg/day) (day-6)
 Phenitoin IV 25mg/12 hours
(7mg/kg/day)
 Paracetamol oral 70 mg/4-6 hours
 Valproat acid 1.8 ml/8 hours
(40mg/kg/day)
Plan
retraction (-),: Erythematous macule (+/+),
papula (+), vesicle (+)
Cor : Heart sound s1-s2 N, murmur (-)
Lung : vesicular breath sound (+)/(+), ronchi
(+/+), wheezing (-/-)
Abdomen : : Erythematous macule (+/+),
papula (-), vesicle (-) bowel sound (+) N,
liver and spleen not palpable
Genitalia : : Erythematous macule (+/+),
papula (+), vesicle (-)
Extremities : edema -/- -/-
Fluid balance: +70.25 ml/24 hour
diuresis 5.3 ml/kgBW/hour
 Steven Johnson Syndrome dd TEN
 General epilepsy
 Microsephal, short stature, wasted
 IVFD D5 ½ NS 240/ 10ml/hour
 Methylprednisolone IV 7.5 mg/24 hours
(1mg/kg/day) (day-7)
 Phenitoin IV 10mg/8 hours (5mg/kg/day)
 Paracetamol oral 70 mg/4-6 hours
 Valproat acid 1.8 ml/8 hours
(40mg/kg/day)
 Levetiracetam oral 125mg-0-125mg

 Levetiracetam oral 125mg-0-125mg (35mg/kg/day)

(35mg/kg/day)
 Piridoxin oral 10mg/8 hours
 Fusidic acid topical/8 hours
 Mumetason topical cream/ 12 hours
 Urea cream / 12 hour
 Lyteers eye drop
Nutrition ONS 100 ml 6 times a day + Breast milk
 Topiramat 25mg ½ tab-0-1/2 tab
 Piridoxin oral 10mg/8 hours
 Fusidic acid topical/8 hours
 Mumetason topical cream/ 12 hours
 Urea cream / 12 hour
 Lyteers eye drop
ONS 100 ml 6 times a day + Breast milk

22
 Programme - Fluid balance and diuresis/12 hours
- Wait for blood culture result (10/3/2020)
- Physioterapy
Day of Admission Follow up day 5 (Admission day 7)
(17/03/2020)
Time 06.00 AM
Bleeding in lip mucosa (+), new vesicle (-),
Subjective new bullae (-),cough (+), seizure 2x, duration
5-10 seconds.
General Alert, active
Vital signs HR 130 bpm, RR 28 times/mins, t 36.30C
P : regular, adequate volume/pressure
BW : 6,53 kg
Physical Face : Erythematous macule (-/-), papula (-),
examination vesicle (-), ekscoriation (+)
Eyes: Secret (+/+). Conjunctiva injection +/-,
papule -, erythema -
Nose : Nose flaring (-), crustae (+)
Mouth: crustae (+), hyperemis (+), papula
(-), ulcer (+)
Chest : symmetry, subcostal and intercostal
Objectives
retraction (-),: Erythematous macule (+/+),
papula (+), vesicle (+), ekscoriation (+)
Cor : Heart sound s1-s2 N, murmur (-)
Lung : vesicular breath sound (+)/(+), ronchi
(+/+), wheezing (-/-)
Abdomen : : Erythematous macule (+/+),
papula (-), vesicle (-) bowel sound (+) N,
liver and spleen not palpable, ekscoriation
(+)
Genitalia : : Erythematous macule (+/+),
papula (+), vesicle (-)
Extremities : edema -/- -/-
Fluid balance: +70.5 ml/24 hour
diuresis 5.6 ml/kgBW/hour
Additional
examination
Assesment  Steven Johnson Syndrome dd TEN
 General epilepsy
 Microsephal, short stature, wasted
Plan
Medical  IVFD D5 ½ NS 240/ 10ml/hour
therapy  Phenitoin IV 10mg/8 hours (5mg/kg/day)
 Methylprednisolone oral 8 mg/24 hours
(1.2 mg/kg/day) (day-8)
 Paracetamol oral 70 mg/4-6 hours
 Valproat acid 1.8 ml/8 hours
(40mg/kg/day)
 Levetiracetam oral 125mg-0-125mg
(35mg/kg/day)
 Topiramat 25mg ½ tab-0-1/2 tab
 Piridoxin oral 10mg/8 hours
 Fusidic acid topical/8 hours
 Mumetason topical cream/ 12 hours
 Urea cream / 12 hour
 Lyteers eye drop
- Fluid balance and diuresis/12 hours
- Physioterapy
Follow up day 6 (Admission day 8)
(18/03/2020)
06.00 AM
New vesicle (-), new bullae (-),cough (+),
seizure 1x, duration 5-10 seconds, refuse to
drink orally
Alert, active
HR 132 bpm, RR 26 times/mins, t 36.30C
P : regular, adequate volume/pressure
BW : 6,53 kg
Face : Erythematous macule (-/-), papula (-),
vesicle (-), ekscoriation (+)
Eyes: Secret (+/+). Conjunctiva injection -/-,
papule -, erythema -
Nose : Nose flaring (-), crustae (+)
Mouth: crustae (+), hyperemis (+), papula
(-), ulcer (+)
Chest : symmetry, subcostal and intercostal
retraction (-),: Erythematous macule (+/+),
papula (+), vesicle (+), ekscoriation (+),
crustae (+)
Cor : Heart sound s1-s2 N, murmur (-)
Lung : vesicular breath sound (+)/(+), ronchi
(-/-), wheezing (-/-)
Abdomen : : Erythematous macule (+/+),
papula (-), vesicle (-) bowel sound (+) N,
liver and spleen not palpable, ekscoriation
(+)
Genitalia : : Erythematous macule (+/+),
papula (+), vesicle (-)
Extremities : edema -/- -/-
Fluid balance: +99.5 ml/24 hour
diuresis 5 ml/kgBW/hour
 Steven Johnson Syndrome dd TEN
 General epilepsy
 Microsephal, short stature, wasted
 IVFD D5 ½ NS 240/ 10ml/hour
 Phenitoin oral 10mg/8 hours
(5mg/kg/day)
 Methylprednisolone oral 8 mg/24 hours
(1.2 mg/kg/day) (day-8)
 Paracetamol oral 70 mg/4-6 hours
 Valproat acid 1.8 ml/8 hours
(40mg/kg/day)
 Levetiracetam oral 125mg-0-125mg
(35mg/kg/day)
 Topiramat 25mg ½ tab-0-1/2 tab
 Piridoxin oral 10mg/8 hours
 Fusidic acid topical/8 hours
 Mumetason topical cream/ 12 hours
 Urea cream / 12 hour
23
  Lyteers eye drop
Nutrition ONS 100 ml 6 times a day + Breast milk ONS 100 ml 6 times a day + Breast milk

Programme - Fluid balance and diuresis/12 hours - Fluid balance and diuresis/12 hours
- Physioterapy - - Physioterapy
- Complete blood count, differential count,
blood smear
Day of Admission Follow up day 7 (Admission day 9)
(19/03/2020)
Time 06.00 AM
New vesicle (-), new bullae (-),cough (+),
Subjective seizure 4x, duration 5-10 seconds, refuse to
drink orally, NGT expulse (+)
General Alert, active
Vital signs HR 124 bpm, RR 26 times/mins, t 36.50C
P : regular, adequate volume/pressure

BW : 6,45 kg
Physical Face : Erythematous macule (-/-), papula (-),
examination vesicle (-), ekscoriation (+)
Eyes: Secret (+/+). Conjunctiva injection -/-,
papule -, erythema -
Nose : Nose flaring (-), crustae (+)
Mouth: crustae (+), hyperemis (+), papula
(-), ulcer (+)
Chest : symmetry, subcostal and intercostal
retraction (-),: Erythematous macule (+/+),
papula (-), vesicle (-), ekscoriation (+),
crustae (+)
Objectives

Cor : Heart sound s1-s2 N, murmur (-)

Lung : vesicular breath sound (+)/(+), ronchi
(-/-), wheezing (-/-)
Abdomen : : Erythematous macule (+/+),
papula (-), vesicle (-) bowel sound (+) N,
liver and spleen not palpable, ekscoriation
(+)
Genitalia : : Erythematous macule (+/+),
papula (+), vesicle (-)
Extremities : edema -/- -/-
Fluid balance: -94.5 ml/24 hour
diuresis 2.5 ml/kgBW/hour
Additional Hb 10.7 Ht 35,4 Leucoyt 16800 Platelet
examination 50000
E1 Ba0 Stab 0 Seg 53 Lym 31 Monocyt 13
Erytocyt: mild anysocytosis
Leucocyt : Monosytosis +, activated
lymphocyte +
Platelet:Normo size +
Assesment  Steven Johnson Syndrome dd TEN
 General epilepsy
 Microsephal, short stature, wasted
Plan

Medical  IVFD D5 ½ NS 120/ 5ml/hour

therapy  Phenitoin oral 10mg/8 hours
(5mg/kg/day)
 Methylprednisolone oral 8 mg/24 hours
(1.2 mg/kg/day) (day-8)
 Paracetamol oral 70 mg/4-6 hours
 Valproat acid 1.8 ml/8 hours

24
 (40mg/kg/day)
 Levetiracetam oral 125mg-0-125mg
(35mg/kg/day)
 Topiramat 25mg ½ tab-0-1/2 tab
 Piridoxin oral 10mg/8 hours
 Fusidic acid topical/8 hours
 Mumetason topical cream/ 12 hours
 Urea cream / 12 hour
 Lyteers eye drop
Nutrition ONS 100 ml 6 times a day + Breast milk

Programme - Permitted to be discharged

25
 IX. COURSE OF THE DISEASE

March 13-14th (D1-2) AD3-4 March 15-16th (D3-4) AD5-6 March 17th (D5) AD7 March 18th (D6) AD8 March 19th (D7) AD9

Fever (-), new vesicle (-), intake via New vesicle (-), new
NGT, cough (+), seizure (-), bullae (-),cough (+),
defecation 3 times/ day cough (+), seizure 1x,
duration 5-10 seconds, seizure 4x, duration 5-10
Multiple Erythematous macule Fever (-), vomiting (-), new seconds BW 6.45kg
(+/+), papula (+), vesicle (+) Bleeding in lip mucosa (+), refuse to drink orally
vesicle (-), crustae (+), cough Erythematous macule (-/-),
Eyes: Secret (+/+). Conjunctiva new vesicle (-), new bullae
(+), seizure (+) intake direct papula (-), vesicle (-),
injection +/-+ (-),cough (+), seizure, BW :
breast feeding, NGT ekscoriation (+) Assessment:
Lung : vesicular breath sound 6.53 kg
Multiple Erythematous macule  Steven Johnson
(+)/(+), ronchi (+/+), wheezing (-/-) Erythematous macule (-/-),
(+/+), papula (+), vesicle (+) Syndrome dd TEN
Genitalia : : Erythematous macule papula (-), vesicle (-),
BW 6.58kg Assessment:  General epilepsy
(+/+), papula (+), vesicle (+) ekscoriation (+)
 Steven Johnson Microsephal, short
Hb 11. Leucocyt 22400 Platelet
Syndrome dd TEN stature, wasted
531000 Seg48 Lymphocyt 39
Assessment:  General epilepsy
Steven Johnson Microsephal, short
Syndrome dd stature, wasted Programme:
Assessment: Assessment:
TEN  Phenitoin oral
Steven Johnson Steven Johnson
General epilepsy (5mg/kg/day)
Syndrome dd TEN Syndrome dd TEN
Microsephal, short  Methylprednisolone
General epilepsy General epilepsy Programme:
stature, wasted oral (1.2 mg/kg/day)
Microsephal, short Microsephal, short  IVFD D5 ½ NS 240/
(day-8)
stature, wasted stature, wasted Programme: 10ml/hour
 Valproat acid
 IVFD D5 ½ NS 240/  Phenitoin oral
40mg/kg/day)
Programme : 10ml/hour (5mg/kg/day)
 Levetiracetam oral
 IVFD D5 ½ NS 360/ 15ml/hour  Phenitoin IV (5mg/kg/day)  Methylprednisolone oral
(35mg/kg/day)
 Methylprednisolone IV 15  Methylprednisolone oral (1.2 mg/kg/day) (day-8)
Programme:  Topiramat 25mg ½
mg/24 hours (2mg/kg/day) (1.2 mg/kg/day) (day-8)  Valproat acid
 IVFD D5 ½ NS 240/ tab-0-1/2 tab
(day-4-5)  Paracetamol oral 40mg/kg/day)
10ml/hour Piridoxin oral
 Paracetamol oral 70 mg/4-6  Valproat acid 40mg/kg/day)  Levetiracetam oral Lyteers eye
 Phenitoin IV (7mg/kg/day)
hours  Levetiracetam oral (35mg/kg/day) drop
 Methylprednisolone IV
 Valproat acid 1.8 ml/8 hours (35mg/kg/day)  Topiramat 25mg ½ tab-0- Permitted to be
(1mg/kg/day) (day-6-7)
(40mg/kg/day)  Topiramat 25mg ½ tab-0-1/2 1/2 tab discharged
 Paracetamol oral
 Levetiracetam oral 125mg-0- tab  Piridoxin oral
 Valproat acid (40mg/kg/day)
125mg (35mg/kg/day)  Levetiracetam oral  Piridoxin oral
 Piridoxin oral 10mg/8 hours (35mg/kg/day)  Fusidic acid topical
 Fusidic acid topical/8 hours  Mumetason topical cream 26
 Piridoxin oral 10mg/8 hours
 Urea cream
Lyteers eye drop
 X. PROGNOSIS

Quo ad vitam : ad bonam

Quo ad sanam : dubia ad bonam
Quo ad fungsionam : dubia ad bonam

27
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