Patient diagnosis, treatment and medication


Name: Date: 26th feb.2020
Sex: Age/DOB/Place of Birth:  6 years
Historian: Present Concerns/CC:

A rash and pain in the mouth



The reason given by the patient for seeking medical care “in quotes.”

Child Profile: (Sexual History (If appropriate); ADLs (age-appropriate); Safety Practices; Changes in daycare/school/after-school care;

Sports/physical activity; Developmental Hx)

The patient was previously healthy and had no history illness before the fist diagnosis done by PCP.



HPI: (must include all components)


The patient is female and six years old and came into the emergency room complaining of mouth rash and pain. The patient had one week earlier presented symptoms of cough, malaise, and subjective fever. The patient had visited the primary care physician who gave her amoxicillin because he presumed she had pneumonia. One week in taking the medication, the patient started developing mouth sores and itchy rash. The patient does not have any known allergies, and she did not present with emesis or diarrhea.





The patient was taking antibiotics (Amoxicillin) as the physician presumed pneumonia




Allergies:   There are no known allergies


Medication Intolerances: there are no known allergies concerning medication


Chronic Illnesses/Major traumas: there is no major trauma although the PCP presumed the patient had pneumonia


Hospitalizations/Surgeries: the patient does not have a history of hospitalization


Immunizations: there is no information on the vaccinations received by the patient



Family History  (Please identify all immediate family)


The patient is with her mother who is her only family mentioned


Social History Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana.  Safety status


The patient is years old and is not working or married. The patient lives with her mother and has no history of drug abuse.



The patient is in distress due to the pain she is experiencing.




The heart rate was 122 beats/min

Her blood pressure was 119/73 mm Hg



She has a rash on her skin,Purpuric macules and bullous lesions on the torso and extremities


The respiratory rate is 18 breaths per minute and oxygen saturation of 97% on room air

An infiltrate in the right lower lobe



she had a conjunctival injection




She had no abnormal findings






The findings were normal


She had ulcers on the tongue and lower lips

















OBJECTIVE (plot height/weight/head circumference along with noting percentiles) Attach growth chart
Weight    42 pounds


Temp 38.9 degrees Celsius BP  119/73
Height 45 inches tall


Pulse 122 beats per minute Resp 18 breaths per minute
General Appearance and parent-child interaction

The patient and the mother seemed quite close and tight. The mother cared for the daughter a lot.



The skin of the patient had sores at the mouth, itchy rashes, and ulcers on the lower lip.








The heart rate of the patient seems to be slightly above that of a 6-year-old, which ranges from 75 to 118 beats per minute. The blood pressure, however, is normal.




The respiratory rate is within the normal range for a 6-year-old













Normal findings


Purpuric macules and bullous lesions on the torso and extremities






Normal findings


In-house Lab Tests – document tests (results or pending)

Chest Xray revealed that the patient had an infiltration in the right lower lobe

Pediatric/Adolescent Assessment Tools (Ages & Stages, etc.) with results and rationale For adolescents (HEADSSSVG Assessment)


The heart rate of the patient seems to be slightly above that of a 6-year-old, which ranges from 75 to 118 beats per minute.



¾  Include at least three differential diagnoses with ICD-10 codes.  (Includes Primary dx and two differentials)

1.      Amoxicillin rash (ICD-10-CM CODE T36.0X5A adverse effects of penicillin, initial encounter) is the first diagnosis because the patient has been taking the drug for the last one week. Penicillin happens to be a medication that most people develop sensitivity towards and leads to side effects such as a rash(Fox, Ghedia& Nash, 2015). The maculopapular outbreak usually grows from 3 to 10 days after starting to take the medications. Since the patient had taken medicine for the past one week, she is likely allergic to the drug.

2.      Steven-Johnson syndrome (SJS) (ICD-10-CM-CODE L51.1). The signs the patient is showing, such as conjunctivitis, oral ulcers, mouth ulcers, and cutaneous purpura, suggest SJS(Maitra, Bhattacharyya, Mukherjee & Era, 2017). The condition arises due to active infection either through the drug she is taking, or new infection.

3.      Bacterial infection (ICD-10-CM CODE A49.9 bacterial infection). The patient has an eye infection caused due to bacterial infection alongside the itchy rash and mouth sores. The bacterial infection can be due to the medications that the patient is taking, which are antibiotics(Fox, Ghedia& Nash, 2015).

4.      Pneumonia (ICD-10-CM CODE J18.9) the symptoms the patient is showing in the objective and subjective data reveals the child could be suffering from pneumonia as presumed by the PCP. The infiltrate in the right lower lobe usually indicates the presence of pneumonia(Iqbal, Qureshi, Shah & Raza, 2016).

¾  Document Evidence-based Rationale for ROS and each differential with pertinent positives and negatives

The PCP had presumed pneumonia, but the patient does not have any other signs apart from the infiltration that suggests the presence of pneumonia. Moreover, it is hard to determine whether the new symptoms are a result of a new infection or a reaction to the antibiotic(Iqbal, Qureshi, Shah & Raza, 2016). All the patient’s vitals were okay except for the heart rate, which was slightly higher, but that could be because of the emergency room atmosphere. The shape and location of a skin rash are a significant consideration when making a diagnosis. Given the location of the skin problems, the signs point to a skin disease caused by the use of the antibiotic(Auyeung & Lee, 2018).

¾  Primary diagnosis

9 Is #1 on the list of differentials


9 Evidence for primary diagnosis should get supported in the Subjective and Objective exams.

SJS is the most probable primary diagnosis because most of the symptoms point to that. Skin conditions are the first symptom that is present in SJS, and the patient developed after starting her medication. The patient had itchy rashes, ulcers of the mouth, lower lip, and tongue, bullous lesions on her torso and extremities indicating SJS. Among the causes of SJS, drug allergies are among them. Most patients are allergic to antibiotics and specifically those containing penicillin such as amoxicillin(St. John et al., 2017). The eyes also get affected by SJS, and the patient had bilateral conjunctival injection showing the spread of SJS in her body.

Given that the patient is a child, it increases the risk of developing SJS as it is common in children than adults. Conditions such as pneumonia cause SJS condition, and given that the patient had received a diagnosis for pneumonia, it may have increased the risk(Sharma, 2018). The symptoms for SJS start showing from one to three weeks, and the patient has been having the symptoms since starting to take medications one week earlier.

PLAN including education

¾  Plan:  Treatment plan should be for the Primary Diagnosis and based on EB literature.

The treatment plan when a patient has SJS is first to stop what is triggering the infection. In this case, the patient has to stop taking the amoxicillin that is making her develop the symptoms. Hospitalization is essential to keep the girl under close observation in the intensive care unit(St. John et al., 2017). Supportive care using intravenous fluids and electrolyte replacement is critical. Comprehensive wound care would help in addressing skin infections. Pain management is crucial because the patient was complaining of pain, especially in the lower extremities. Respiratory and nutritional support will help keep the patient comfortable and boost energy levels in children(Sharma, 2018).

There is a need for the patient to see an ophthalmology consultant due to the conjunctiva infection to determine the best course of treatment.

¾  Include EB rationale for all aspects of your treatment plan:

9 Vaccines administered this visit



9 Vaccine administration forms given


9 Medication-amounts and mg/kg for medications

Oral corticosteroids 2mg/kg/day for seven days (Auyeung & Lee, 2018)

Cyclosporine 3-5mg/kg/day for 14 days (St. John et al., 2017)


IVIG 2-4 g/kg for four days (Auyeung & Lee, 2018)

9 Laboratory tests ordered

1.          Blood tests are critical in checking for an infection(Sharma, 2018)

2.          Culture laboratory test


9 Diagnostic tests ordered

1.      Physical examination

2.      Skin biopsy helps in conforming the diseases and ruling out any other infection

3.      Imaging using an Xray to check for pneumonia(Auyeung & Lee, 2018)

4.      Blood pressure, respiratory rate, heart rate, pulse rate

9 Patient education including preventive care and anticipatory guidance

Patient education would include tips on how to manage the condition well. Knowledge of the use of corticosteroids to control skin inflammation will enable the patient and the parent to maintain the skin breakout and recover. The patient will learn how to put the eye drops to address the eye-related symptoms. The patient will also receive education on the possible complications that can occur due to SJS, such as skin changes, eye issues, and internal organs such as the lungs, given the patients’ infiltration of the lungs(Sharma, 2018).

9 Non-medication treatments

Supportive care will help the patient deal with the skin conditions and recover as they manage the situation(Iqbal, Qureshi, Shah & Raza, 2016).

9 A follow-up appointment with a detailed plan of  f/u

Follow up will take place at the hospital until the patient progresses well; then, they get discharged(Iqbal, Qureshi, Shah & Raza, 2016). However, regular visits to the hospital are essential o track progress and ensure complete healing.


Auyeung, J., & Lee, M. (2018). Successful Treatment of Stevens-Johnson Syndrome with Cyclosporine and Corticosteroid. The Canadian Journal Of Hospital Pharmacy, 71(4). doi: 10.4212/cjhp.v71i4.2829

Fox, R., Ghedia, R., & Nash, R. (2015). Amoxicillin-associated rash in glandular fever. BMJ Case Reports, bcr2015211622. doi: 10.1136/bcr-2015-211622

Iqbal, H., Qureshi, M., Shah, O., & Raza, S. (2016). Steven Johnson Syndrome – A triad of mucosal lesions, cutaneous involvement, and history of recent drug exposure. International Archives Of Biomedical And Clinical Research, 2(2). doi: 10.21276/iabcr.2016.2.2.19

Maitra, A., Bhattacharyya, S., Mukherjee, S., & Era, N. (2017). A rare case of oxcarbazepine induced Stevens-Johnson Syndrome: toxic epidermal necrosis overlap. International Journal Of Basic & Clinical Pharmacology, 6(2), 466. doi: 10.18203/2319-2003.ijbcp20170350

Sharma, S. (2018). Understanding the Etiopathogenesis of Steven Johnson Syndrome. Global Journal Of Otolaryngology, 14(1). doi: 10.19080/gjo.2018.14.555879

St. John, J., Ratushny, V., Liu, K., Bach, D., Badri, O., & Gracey, L. et al. (2017). Successful Use of Cyclosporin A for Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis in Three Children. Pediatric Dermatology, 34(5), 540-546. doi: 10.1111/pde.13236

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