erythema multiforme ppt (1)

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B. Chief Complaint: Rashes



History of Present Illness

2 days prior to admission, the patient had

high grade fever (38.8 ° C) associated with

productive, non-distressing cough and

cold. Patient developed urticarial rashes.

Patient sought consult and was prescribed

broxitrol, diphenhydramine and

cephalexine




1 day prior to admission, patient hadintermittent low to high grade fever

(39.8 ° C) and associated with occasional

productive, non-distressing cough withprogression of urticarial rash (upper andlower extremities, back and trunk).Diphenhydramine was shiftedhydroxyzine. Cephalexin and broxitrolwere given.




Few hours prior to admission, patient was

brought to the emergency room due to

progression of urticarial rash associated

with productive cough and colds.



Past Medical History

(-) chicken pox (-) mumps (-) measles

(-) allergy to food and drugs (-) bronchial

asthma

(-) PTB

Patient was previously admitted to Fe Del

Mundo Hospital in June 2012 due to highfevers secondary to urinary tract infection.




Immunizations:

BCG + OPV +++ MMR -

DTP +++ Measles + Hepa B +++

Prenatal:

Born to a 24 year old (G2P2 2002) mother via

normal spontaneous delivery, non-hypertensive,non-diabetic no fetomaternal complications,

unremarkable




Nutrition:

Milk: breast feeding for 2 months

Solids: 6 months

No feeding problems, denies allergy

Growth and Development:

2 months: social smile

8 months: crawling

1 year and 7 months: walked



Family History

(-) asthma

(+) hypertension paternal side

(+) diabetes mellitus maternal side

(-) kidney disease

(-) lung disease



Social History

Patient is the younger of 2 siblings, lives

with parents, drinks mineral water.



Physical Assessment

Temp: 36 ° Celsius

Pulse Rate: 128 bpm

Respiratory Rate: 36 cycles per minute

Blood Pressure: 90/60 mm Hg



General Survey

The patient is well-nourished. He is

aware, coherent, afebrile, alert and

ambulatory. He is not under respiratory

distress or under cardiac distress. Skincolor is normal brown in color, absence of

pallor, absence of urticarial rashes, warm

and moist to touch; skin is elastic withgood turgor



Physical Exam

Parts Method Normal

Findings

Actual

Findings

Interpretations

Skin Inspection

Observation

Skin color varies from light

to deep brown; from ruddy

pink to light pink, from

yellow overtimes to olive.Generally uniform except

in areas exposed to sun;

areas of lighter

pigmentation (palms, lips

nail beds) in dark skin

people. Moisture in the

skin folds and the axillae

(varies with environmental

temperature, and activity).

General color

was light brown.

.

Skin temp.

was normal.

Patient has no

Bruises or

Hematoma on

either side of

arms or legs

Normal Findings

- Bates Guides to

PE and HistoryTaking 10th edition



Physical Exam

Parts Method Normal

Findings

Actual

Findings

Interpretations

Skin Palpation No edema,

abrasions, lesion.

Temperature isuniform and w/in

normal range

Normal Findings

- Bates Guides to




Physical Exam

Parts Method Normal

Findings

Actual

Findings

Interpretations

Nails Inspection Convex curvature; with

smooth texture ,color

is highly vascular &

pink in light skinnedclients; dark skinned

clients may have

brown or black

pigmentation in

longitudinal streaks

with intact epidermis

on tissuesurroundings

-Blanch test- prompt

return of pink or usual

color 3-5 sec.

Convex,

smooth in

texture, color

is pinkish.

Blanch test:

Prompt return

of usual color

(after 3 sec.)

Normal Findings

- - Bates Guides to




Physical Exam

Parts Method Normal Findings Actual

Findings

Interpretations

Scalp Inspection

Palpation

White, clean, free from

masses, lumps scars, lice,

nits, dandruff, and lesions

no area of tenderness

White, clean,

free from

masses,

lumps scars,

lice, nits,

dandruff, and

lesions no

area of

tenderness

Normal findings.

- Bates Guides to




Physical Exam (Eyes)

Parts Method Normal

Findings

Actual

Findings

Interpretations

Eyebrows Inspection Symmetrically

aligned.

Equally distributed,

curled slightly

outward

Hair is evenly

distributed,

skin intact and

aligned.

Symmetrically

aligned and

equal

movement

Normal findings.

- Bates Guides to PE

and History Taking10th edition



Physical Exam

Parts Method Normal

Findings

Actual

Findings

Interpretations

Eyelashes Inspection Equally distributed,

Curled slightly outward Eyelashes

are equally

distributed, it

is curled

outward

Normal findings.

Eyelashes should be

curled outward to sweep

foreign particles awayfrom the eyes.


and History Taking 10th

edition



Physical Exam

Parts Method Normal

Findings

Actual

Findings

Interpretations

Eyelids Inspection The skin is intact, no

discharge and no

discoloration. The lids

close symmetricallyblinks involuntary and

with bilateral blinking.

Lids closes

symmetrically,

bilateral

blinking and novisible sclera

above corneas,

and upper and

lower borders

of cornea are

slightly covered

when lids are

open

Normal findings- Bates

Guides to PE and

History Taking 10th

edition



Physical Exam

Parts Method Normal

Findings

Actual

Findings

Interpretations

Sclera &

Conjunctiva

Inspection Shiny, smooth &

pink or red in

color

Both sclerae

are shiny

and

smooth.Palp

ebral

conjunctivae

is red in

color

Normal findings -

Bates Guides to PE

and History Taking

10th edition



Physical Exam

Parts Method Normal

Findings

Actual

Findings

Interpretations

Pupil & Iris Inspection Black in color, equal

in size, normally 3-7

mm in diameter,

sound- smooth

border iris flat &

sound.

Iris black in

color, equal in

size and round

in shape. Iris isflat and round.

Pupil diameter

is 3mm.

patient’s pupil

constricts

when looking

at near objects

and dilate

when looking

far

Normal findings





Physical Exam

Parts Method Normal

Findings

Actual

Findings

Interpretations

Extraocular

muscle tests

Inspection Both eyes

coordinated,

move in unison

with parallel

alignment

Within

normal

findings.

Normal findings.



Physical Exam

Parts Method Normal

Findings

Actual

Findings

Interpretations

Visual

Acuity Inspection Able to read

newsprint with 20/20

vision on Snellen

chart

The patient

cannot read

the writings

given to him.But can

identify

pictures

Normal

findings



Physical Exam (Ears)

Parts Method Normal

Findings

Actual

Findings

Interpretations

Auricles Inspection

Palpation

The color is same

as facial skin,

symmetrical, theauricles aligned

With outer cantus

of the eye.

Mobile, firm and not

tender, pinna

recoils after it is

folded.

The color is

Same as

facial skin,symmetrical,

The auricles

aligned with

outer cantus

of the eye.

Mobile, firm

and not

tender, pinna

recoils after

it is folded.

Normal Findings





Physical Exam

Parts Method Normal

Findings

Actual

Findings

Interpretations

Hearing

AcuityInspection Normal voice tones

audible. Sound is

heard in both ears orlocalized at the

center of the head

(Weber Negative).

Air conducted

hearing is greater

than bone conducted

hearing (positive

Rinne)

Normal voice

tones

audible.

Sound is

heard in both

ears or

localized at

the center of

the head.

Normal

Findings



Physical Exam (Nose)

Parts Method Normal

Findings

Actual

Findings

Interpretations

Nose Inspection Symmetric and straight

No discharge or flaring

Uniform in color Not

tenderness, no lesion

Symmetric in

shape. No

discharge or

flaring,

uniform in

color. (-)

tenderness

and lesions.

Patient can breathe

normally through

nose and nodischarges.

Normal findings


and History Taking

10th edition



Physical Exam

Parts Method Normal

Findings

Actual

Findings

Interpretations

Facial

Sinuses

Palpation No tenderness

noted.

No

tenderness

Normal findings.


and History Taking

10th edition



Physical Exam

Parts Method Normal

Findings

Actual

Findings

Interpretations

Septum Inspection Air moves freely as the

client breathes through

the nares

Nasal

septum

intact & in

midlineNasal

septum

intact and in

midline

Normal findings


and History Taking

10th edition



Physical Exam (Mouth)

Parts Method Normal

Findings

Actual

Findings

Interpretations

Lips Inspection

Palpation

Uniform pink color

Soft, slightly dry,

smooth texture

Symmetrical

contour

Ability to purse lips

Uniform pink

color

Soft, slightly

dry,

Symmetrical

contour

Ability to

purse lips

Normal findings


and History Taking

10th edition



Physical Exam

Parts Method Normal

Findings

Actual

Findings

Interpretations

Buccal

mucos

a

Inspection Uniform pink color

Soft, moist, smooth

texture

Uniform

pink color

smooth intexture.

Normal findings -

Bates Guides to




Physical Exam

Parts Method Normal

Findings

Actual

Findings

Interpretations

Gums Inspection Pink gums, moist, firm

texture to gums.

Pinkish

gums, no

retraction,

moist and

firm.

Gums are pinkish in

color.

Normal findings


and History Taking

10th edition



Physical Exam

Parts Method NormalFindings

ActualFindings

Interpretations

Tongue Inspection

Palpation

Central position

Pink color, moist,

slightly rough; then,whitish coating

Smooth; lateral

margins; no lesions

Raised papillae

Moves freely, no

tenderness

Smooth tongue base

with prominent veins.

Central

position, pink

in color,

moist,

moves

freely, no

lesions,

tenderness

and nodules

Normal


and History Taking

10th edition



Physical Exam

Parts Method Normal

Findings

Actual

Findings

Interpretations

Teeth Inspection Teeth, smooth, white,

shiny tooth enamel and

pink gums

Patient has deciduous

teeth

Patient has

deciduous

teeth with

some teethmissing

Normal Findings.


and History Taking

10th edition



Physical Exam


Findings

Interpretations

Uvula Inspection Soft, moist, smooth

texture

Pink and smooth.

Soft, moist,

smooth

texture

Pink and

smooth.

Normal Findings


and History Taking

10th edition



Physical Exam

Parts Method Normal

Findings

Actual

Findings

Interpretations

Tonsils Inspections No discharge.

Tonsils of normal

size.

Pink and smooth

posterior wall.

No

discharge.

Tonsils of

normal size.

Pink and

smooth

posterior

wall

Normal Findings-

Bates Guides to PE

and History Taking

10th edition



Physical Exam (Neck)

Parts Method Normal

Findings

Actual

Findings

Interpretations

Neck Inspection

Palpation

Proportional to size of the

head, symmetrical and

straight. Freely movable

without difficulty.

No palpable lumps or

tenderness

The trachea is in the

central placement in

midline of neck, spaces

are equal on both sides

Muscles equal in size,

head centered,

coordinated smooth

movement, head was

Flexed, hyperextended

Laterally flexes,Laterally Rotates

No noted palpable

lymph nodes,

trachea in central

placement in

midline of neckspaces are equal on

both sides, thyroid

gland moves

With deglutition

There are no palpable

lymph nodes. Head can

easily flex and rotates.

Trachea is in the central

placement and no

indication of possibleneck tumor nor thyroid

enlargement

Muscles in the neck like

sternocleidomastoid and

trapezius draw the head

to the side and elevate

the chin and elevate theshoulders to shrug them.

The trachea, thyroid

gland, anterior cervical

nodes and carotid artery

lie within the anterior

triangle.


and History Taking 10th

edition



Physical Exam (Upper Extremities)

Parts Method Normal

Findings

Actual

Findings

Interpretations

Shoulder Inspection

Palpation

Able to tolerate wide

range of motion. No

difficulty upon

bending andstretching. . No

lesions, no scars

and no deformity.

Able to do

ROM , no

scars and

lesions

Normal Findings


and History Taking

10th edition



Physical Exam

Parts Method Normal

Findings

Actual

Findings

Interpretations

Arms

Forearms

Inspection

Palpation


range of motion. No

difficulty upon

bending andstretching. No

lesions, no scars

and no deformity.

Has

capability to

do ROM

exercises.

Normal Findings


and History Taking

10th edition



Physical Exam

Parts Method Normal

Findings

Actual

Findings

Interpretations

Wrists Inspection

Palpation


range of motion. No

difficulty upon bending

and stretching. Nolesions, no scars and

no deformity.

Has ability to

do ROM

exercises

withoutdifficulty in

doing.

Normal Findings


and History Taking

10th edition



Physical Exam

Parts Method Normal

Findings

Actual

Findings

Interpretations

Hands

Fingers

Inspection

Palpation


range of motion. No

difficulty upon bending

and stretching. . Nolesions, no scars and

no deformity.

Has ability to

do ROM

exercises

withoutdifficulty

Normal Findings


and History Taking

10th edition



Physical ExamParts Method Normal Findings Actual Findings Interpretations

Anterior Inspection

Palpation

Percussion

Quiet, rhythmic and

effortless respiration.

Full and symmetric

chest expansion.

Same as posterior

vocal fremitus,

fremitus is normally

decreased over heart

and breast tissue.

Notes resonate down

to the 6th rib at the

level of the diaphragmbut are flat over areas

of heavy muscle and

bone, dull on areas

the heart and the

liver, and tympanic

over the underlyingstomach

Quiet rhythmic andeffortless.

Full and symmetric

chest expansion.

Normal findings- Bates Guides to

PE and History

Taking 10th

edition



Physical Exam (Abdomen)

Parts Method Normal

Findings

Actual

Findings

Interpretations

Skin

Integrity

Inspection Unblemished skin,

uniform in color .Unblemished

skin, uniform

in color .

Normal findings


and History Taking

10th edition



Physical Exam

Parts Method Normal

Findings

Actual

Findings

Interpretations

Contour

and

Symmetry

Inspection Flat, rounded.

Symmetric contour.

Flat,

rounded.

Symmetric

contour.

Normal findings


and History Taking

10th edition



Physical Exam

Parts Method Normal

Findings

Actual

Findings

Interpretations

Movement Inspection Symmetric

movements caused

by respiration.

Symmetric

movement

caused by

respiration,no visible

vascular

pattern

Normal findings


and History Taking

10th edition



Physical Exam

Parts Method Normal

Findings

Actual

Findings

Interpretations

Genitalia Not

Assessed



Physical Exam (Lower Extremities)


Findings

Interpretations

Hip Inspection Able to perform wide

range of motion. No

masses, scars and

deformity.

Able to

perform wide

range of

motion. Nomasses,

scars and

deformity.

Normal Findings


and History Taking

10th edition



Physical Exam


Findings

Interpretations

Leg Inspection

Palpation

Able to perform wide

range of motion. No

masses, scars and

deformity

Able to

perform

range of

motion.

Normal Findings-

Bates Guides to PE

and History Taking

10th edition



Physical Exam

Parts Method Normal

Findings

Actual

Findings

Interpretations

Knee Inspection

Palpation

Able to perform wide

range of motion. No

masses, scars and

deformity.

Has no

difficulty

moving the

left knee

Normal Findings


and History Taking

10th edition



Physical Exam

Parts Method Normal

Findings

Actual

Findings

Interpretations

Foot

and

Toes

Inspection

Palpation

Able to perform

wide range of

motion. No

masses, scarsand deformity.

Right foot is

comfortable to

perform wide

range of motion

Normal Findings


and History Taking

10th edition



Gordon’s Functional Health Patterns

Patterns

Of

Functioning

Prior to

Hospitalization

During

Hospitalization

Analysis

Self Perception

Pattern

Sexuality and

ReproductivePattern

Not assessed

Not assessed

Not assessed

Not assessed




Patterns

Of

Functioning

Prior to

Hospitalization

During

Hospitalization

Analysis

Cognitive

Perceptual

Pattern

The client is

mentally oriented,can do simple

and complex

commands.

The patient is

oriented, canfollow simple

commands and

can answer

questions asked

by the nurse

There are no

changes in thecognitive

perceptual

pattern




Patterns

Of

Functioning

Prior to

Hospitalization

During

Hospitalization

Analysis

Value Belief

Pattern

The patient was born

Catholic and theypractice Catholic

culture like going to

mass every Sunday

and the value of

prayers.

The patient was born

Catholic and theypractice Catholic

culture like going to

mass every Sunday

and the value of

prayers.

There are no changes

in the value-beliefpattern of the client.




Patterns

Of

Functioning

Prior to

Hospitalization

During

Hospitalization

Analysis

Elimination The client

urinates 3-4times daily and

defecates 2 times

a day

The client

urinates 3-5times every day

and defecates

twice.

There are no

changes inelimination

pattern of the

client.




Patterns

Of

Functioning

Prior to

Hospitalization

During

Hospitalization

Analysis

Activity Exercise

Pattern

The patient is

physically active

He remains in

bed most of thetime and would

spend most of

the time sleeping

or waking up to

eat

Activity and

exercise patternmay be limited

during

hospitalization

because of the

patient’scontraptions

(IVF).




Patterns

Of

Functioning

Prior to

Hospitalization

During

Hospitalization

Analysis

Sleep Rest

Pattern

The patient

sleeps 6-7 hourseveryday and

rests in the

afternoon for his

naps.

The patient has

enough rest andsleeps as often

as possible but

needs to wake up

because of some

nursingprocedures.

There’s an

altered sleepingpattern in the

hospital because

health workers

enter the room

and conductneeded tests.




Patterns

Of

Functioning

Prior to

Hospitalization

During

Hospitalization

Analysis

Nutrition The client has a

good appetiteespecially when

he likes the food.

He is fond of

drinking his milk

and pasta.

The client drinks

milk and eats fishmost of the time.

Being

hospitalizedaffected the

client’s eating

habits.




PatternsOf

Functioning

Prior toHospitalization

DuringHospitalization

Analysis

Safe

Environment

They live in a

safe residentialplace Caloocan.

They are much

safer in thehospital.

Environment is

important todetermine the

etiology of the

disease – how it

started and how

can beprevented.

M t M il D l t l S i



Metro Manila Developmental Screening

Test

Passed

(P)

Failed

(F)

Refused

(R)

NoOpportunity

Personal Social

1.) child’s ability to get

along with people- ask the child how his

day went

2.) to take care of himself

- ask the child to comb

hair

P

P

Metro Manila De elopmental Screening




Test

Passed

(P)

Failed

(F)

Refused

(R)

NoOpportunity

Fine-Motor Adaptive

1.) Child’s ability to see

-Ask the child if he cansee colored object

2.) Child’s ability to use

his hands to pick up

objects

- Ask he child to pick

up an object

P

P





Test

Passed

(P)

Failed

(F)

Refused

(R)

NoOpportunity

Fine-Motor Adaptive

3.) Child’s ability to draw

object- Ask the child to draw

a tree on a piece of

paper

P





Test

Passed

(P)

Failed

(F)

Refused

(R)

NoOpportunity

Language

1.) Child’s ability to hear

- Ask the child ifhe/she can hear

sound

2.) Child’s ability to follow

directions

- Ask the child to pointfinger to tip of nose

P

P





Test

Passed

(P)

Failed

(F)

Refused

(R)

NoOpportunity

Language

3.) Child’s ability to speak

- Speak to child abouthis/her favorite food

and describe

P





Test

Passed

(P)

Failed

(F)

Refused

(R)

NoOpportunity

Gross Motor

1.) Child’s ability to sit,

walk and jump- Ask the child to sit

- Ask the child to walk

and

- Ask the child to jump

P

P

P



Lab and Diagnostic

Chest X-Ray

Bilateral infrahilar densities

Impression: PPTB, bilateral

Lab and Diagnostic



Lab and Diagnostic

CBC

Patient’s

Value

Normal

Value

Rationale

RBC 5.56 3.8 - 5.5 x

10ˆ6/uL

HgB 10.3 11 - 14 g/dL Low HgB, Low

Hct, Low MCV

occurs in

microcytic anemiairon deficiency

(Kaplan Medical,

"Pathology" 2008)

Lab and Diagnostic



Lab and Diagnostic

CBC

Patient’sValues

NormalValue

Rationale

Hct 30% 31% - 41% Low HgB, Low

Hct, Low MCV

occurs in


anemia (Kaplan

Medical,

"Pathology" 2008)

Lab and Diagnostic



Lab and Diagnostic

CBC

Patient’sValues

NormalValue

Rationale

MCV 55 70 - 85 fL Low HgB, Low

Hct, Low MCV

occurs in


anermia (Kaplan

Medical,

"Pathology" 2008)

Lab and Diagnostic



Lab and Diagnostic

CBC

Patient’sValues

NormalValue

Rationale

MCH 19 21 – 31 pg Low MCH occurs

in microcytic

anemia, iron

deficiency anemia(Kaplan Medical,

"Pathology" 2008)



Lab and Diagnostic



Lab and Diagnostic

CBC

Patient’sValues

NormalValue

Rationale

WBC 6.74 3.8 - 11 x

10ˆ3 /mm3

Lab and Diagnostic



Lab and Diagnostic

CBC

Patient’sValues

NormalValue

Rationale

Neutrophils 50% 50 – 81%

Lab and Diagnostic



Lab and Diagnostic

CBC

Patient’sValues

NormalValue

Rationale

Reticulocyte 0.6% 0.5% -

1.5%

Lab and Diagnostic



Lab and Diagnostic

CBC

Patient’sValues

NormalValue

Rationale

Lymphocyte 46% 14% - 44% The epidermal

layer of the skin

becomes

infiltrated withlymphocytes in

erythema

multiforme

(“Erythema

Multiforme”, Jose

Plaza, MD e-

Lab and Diagnostic



Lab and Diagnostic

CBC

Patient’sValues

NormalValue

Rationale

Eosinophil 1% 1% -2%

Lab Diagnosis



Lab Diagnosis

U/A

Color: Light yellow

Transparency: Hazy

Specific Gravity: 1.010

Reaction: 6.5

Sugar: Negative

Albumin: Negative

Lab Diagnosis



Lab Diagnosis

U/A

Microscopic

Pus cells: 0-2/ HPF

RBC: 0-1/HPF

Epithelial: Few

Bacterial: Few

Lab Diagnosis



Lab Diagnosis

U/A

Mucus Threads: Rare Amorphous: Few

Leukocyte: Negative

Nitrate: Negative

Urobilinogen: Normal

Blood: Negative

Ketone: Negative

Bilirubin: Negative



IV. Initial Impression

Hypersensitivity secondary to food intake

V. Final Diagnosis

Erythema Multiforme

Anatomy of the Skin



y

A t d Ph i l



Anatomy and Physiology

A t d Ph i l




Skin Physiology: Structure andFunction Basics

Skin has two main structural layers—

the epidermis and the dermis.

• The epidermis is the outer layer of skin, which

serves as the physical and chemical

barrier to the interior body and exterior environment. • The dermis is the deeper layer providing the

structural support of the skin.

A t d Ph i l




Epidermis and Stratum Corneum: TheStructure and Growth of Skin

The epidermis consists of stacked layers of cells in

transition. Protein bridges called desmosomes connect thecells.

The bottom layer of cells adjacent to the dermis are the

basal cells which reproduce.

As the cells mature, they move towards the outer layer of

skin leading to terminal differentiation of the cells.

A t d Ph i l




During the process of maturation, the physiology, chemicalcomposition, shape and orientation of the cells change.

When the cells reach the top layer of skin — the stratum

corneum —

the cells are called corneocytes and are nolonger viable. Corneocytes lack a nucleus and cellular

structures.

A t d Ph i l




Corneocytes are flat, hexagonal-shapedcells filled with water-retaining keratin

proteins surrounded by a protein

envelope and lipids.

The cellular shape and the orientation

of the keratin proteins add strength tothe stratum corneum. There are 10-30layers of stacked corneocytes.

A t d Ph i l




The thicker skin on the palms and soles hasthe most layers of stacked corneocytes.

The cells remain connected to each other byprotein bridges called desmosomes.

Stacked bilayers of lipids surround the cells

in the extracellular space. The resultingstructure is the natural physical and water-retaining barrier of the skin

P th h i l



Pathophysiology

Etiology of ERYTHEMA MULTIFORME

Erythema multiforme minor is regarded as

being commonly triggered by herpes

simplex virus (HSV) (types 1 and 2), andHSV is the most common cause in young

adults;

Pathoph siolog



Pathophysiology

Bacterial Bacterial infections include borreliosis, catscratch

disease, diphtheria, hemolytic streptococci, legionellosis,leprosy, Neisseria meningitidis, Mycobacterium avium

complex, M pneumoniae, pneumococci,tuberculosis,Proteus Pseudomonas

Salmonella Staphylococcus

Yersinia species, Treponema pallidum, tularemia, Vibrio parahaemolyticus, Vincent disease, and rickettsial

infections. Chlamydial infections includelymphogranuloma venereum and psittacosis.

Pathophysiology



Pathophysiology

Viral Viral infections include Adenovirus, coxsackievirus B5,

cytomegalovirus (CMV), echoviruses, enterovirus,

Epstein-Barr virus (EBV), hepatitis A / B / C viruses

(HAV / HBV / HCV), HSV, influenza, measles, mumps,paravaccinia, parvovirus B19, poliomyelitis, varicella-

zoster virus (VZV), and variola.

Virus-drug interactions include CMV infection –

terbinafine and EBV infection –amoxicillin.

Pathophysiology



Pathophysiology

Other Fungal infections include coccidioidomycosis,

dermatophytosis, and histoplasmosis.

Parasitic infections include Trichomonas speciesand Toxoplasma gondii .

Pathophysiology



Pathophysiology

Drugs More than 50% of cases are related to medication use,

but no test reliably proves the link between a single case

and a specific drug.

Regarding medications, sulfa drugs are the most

common triggers (30%). A slow acetylator genotype is a

risk factor for sulfonamide-induced Steven-Johnson

syndrome

.

Pathophysiology



Pathophysiology

DrugsThe second most commonly involved

agents are the anticonvulsants, including

barbiturates,carbamazepine,hydantoin,phenytoin, and valproic acid. Prophylacticanticonvulsants after surgery for a braintumor combined with cranial irradiation

may result in life-threatening Steven-Johnson syndrome.

Pathophysiology



Pathophysiology

Drugs

Causative antibiotics include penicillin,

ampicillin, tetracyclines, amoxicillin,

cefotaxime, cefaclor, cephalexin,ciprofloxacin, erythromycin, minocycline,

sulfonamides, trimethoprim-

sulfamethoxazole, and vancomycin

Pathophysiology



Pathophysiology

Erythema Multiforme is caused by a Type IVHypersensitivity (Delayed Type

Hypersensitivity or T Cell Lymphocyte

mediated)

Type IV Hypersensitivity are seen in contact

dermatitis and Mantoux test, Diabetes

Mellitus Type I, Hashimoto’s Thyroiditis,

Multiple Sclerosis, Guillaine BarréSyndrome,

Pathophysiology



Pathophysiology

Type IV Hypersensitivity:

- mediated by Th1 cells ( a subtype of

lymphocytes which causes tissue

damage)

Pathophysiology



Pathophysiology

1) There is contactwith the antigen or

exposure to an

allergen

Pathophysiology



Pathophysiology

2) During the contactor exposure to the

allergen, a small

molecule called a

HAPTEN binds with a

carrier protein in the

host

Pathophysiology



Pathophysiology

3) The carrier proteinwith bound hapten is

ingested by a

macrophage

Pathophysiology



Pathophysiology

4) The hapten peptideis then presented on

the cell surface of the

macrophage as MHC

Class II

Pathophysiology



Pathophysiology

5) Th1 cell with T-cell receptors

recognizes the

hapten peptide

antigen and

interacts with MHC

Class II

Pathophysiology



Pathophysiology

6.) After interaction,Th1

cells increase in

number

7.) A second exposure

to the allergen, the Th1

cells again react with

the hapten-petide

antigen thus releasingcytokines

Pathophysiology



Pathophysiology

8.) Cytokines result inattraction of moremacrophages followed byinflammation and skinlesions

9.) The epidermal layer of theskin then becomes infiltratedwith lymphocytes andmacrophages (specificallyTh1 cells, IFN gamma, TNF,

IL-2).

Pathophysiology



Pathophysiology

10.) Characteristic skin lesionsappear after 24 hours reaching

their peak at 48 to 72 hours

after more exposure to allergen.

Erythema multiforme produces

a raised, atypical target skin

lesions.

DRUG STUDY



DRUG STUDY

DRUG NAME

Generic:

Cetirizine HCl

Brand:

Zyrtec

DRUG STUDY



DRUG STUDY

CLASSIFICATION

Anti-histamine

DRUG STUDY



DRUG STUDY

ROUTE

Child (6 mos to 5 years old):

5 mg/ 5ml

2 ml OD PO

DRUG STUDY



DRUG STUDY

MECHANISM OF ACTION

A potent H1-receptor antagonist, does not

cross the blood brain barrier therefore

relative lack of anti-cholinergic propertiesand sedation

DRUG STUDY



DRUG STUDY

INDICATION

Season and perennial allergic rhinitis and

chronic idiopathic urticaria

DRUG STUDY



DRUG STUDY

CONTRAINDICATIONS

Hypersensitivity to H1-receptor anti-

histamines or hydroxyzine, infants younger

than 6 months

DRUG STUDY



DRUG STUDY

SIDE EFFECTS

Constipation, diarrhea, dry mouth

DRUG STUDY



DRUG STUDY

Nursing Implications Assessment:

Obtain thorough patient history of allergy symptoms(rhinitis, conjunctivitis, hives) before and periodicallyduring therapy

Physical Exam: obtain baseline vital stats, liver, renal,cardiac function

Diagnosis:

Altered skin integrity related to medication

Planning:

Give medication once daily without regard to food

DRUG STUDY



DRUG STUDY

Nursing Implications Implementation:

Instruct patient to take medication as directed.

May cause dizziness and drowsiness. Caution patient to avoiddriving or other activities requiring alertness until response tomedication is known.

Advice patient that good oral hygiene, frequent rinsing of mouth with water, sugarless gum or candy will minimize

dry mouth

Instruct patient to contract health care professional if dizzinesspersists.

Evaluation

Monitor patient response to drug therapy

Monitor for adverse effects (orientation, blood pressure)

Evaluate effectiveness of teaching plan

DRUG STUDY



DRUG STUDY

DRUG NAME

Generic: Prednisone

Brand Name: Deltasone

DRUG STUDY



DRUG STUDY

CLASSIFICATION

Adrenal Corticosteroid

DRUG STUDY



DRUG STUDY

DOSAGE/ROUTE

Child:

100 mg/ml give 3 mL q12° PO

DRUG STUDY



DRUG STUDY

MECHANISM OF ACTION

Suppresses inflammation by inhibition of

leukocyte infiltration and suppression of

humoral immune response

DRUG STUDY



DRUG STUDY

INDICATION

Allergic conditions, skin conditions,

ulcerative colitis, arthritis, psoriasis

DRUG STUDY



CONTRAINDICATIONS

Systemic fungal infections, known

hypersensitivity, cataracts

DRUG STUDY



SIDE EFFECTS

Nausea, vomiting, peptic ulcer, Cushingoid

features, growth suppression in children,

hyperglycemia, osteoperosis

DRUG STUDY



Nursing ImplicationsAssessment:

Establish baseline and continuing data regarding BP, I & O ratio pattern,weight, fasting blood glucose levels, and sleep pattern.

Check and record BP during dose stabilization period at least 2 times daily.Report an ascending pattern

Monitor patient for evidence of HPA axis suppression during long-termtherapy.Be alert of signs of hypocalcemia. Patients with hypocalcemia.Patients with hypocalcemia have increased need of pyroxidine (Vit B6),Vitamin C, Vitamine D and folate

Be alert to possibility of masked infection and delayed healing (anti-inflammatory and immunosuppressive actions). Prednisone suppressesearly classic signs of inflammation. When patient is on extended therapyregimen, incidence of oral Candida is high. Inspect mouth daily forsymptoms. White patches, black furry tongue, painful membranes andtongue

DRUG STUDY



Nursing Implications Planning:

Crush tablet and give with fluid of choice if unable to swallow whole

Give at mealtimes or with snack to prevent gastric irritation

Do not abruptly stop drug. Reduce drug dose in decrements to preventwithdrawal symptoms and permit adrenals to recover from drug-inducedpartial atrophy.

Implementation

Take drug as prescribed and do not alter dosing regimen or stop medicationwithout consulting physician

Be aware that a slight weight gain with improved appetite is expected

Report symptoms of GI distress to physician and do not self-medicate tofind relief

Do not use OTC drugs or aspirin unless specifically prescribed by physician

DRUG STUDY



Nursing ImplicationsEvaluation:

Monitor patient response to drug therapy

Monitor for adverse effects to drug therapy

Evaluate effectiveness of health teaching

DRUG STUDY



DRUG NAMEGeneric Name:

Cefixime

Brand Name:

Suprax

DRUG STUDY



CLASSIFICATIONThird-generation anti-biotics

DRUG STUDY



DOSAGE/ROUTEChild:

100 mg/ 5 ml give 3 ml q 12°

DRUG STUDY



MECHANISM OF ACTIONSBinds to specific penicillin-binding proteins

(PBPs) located inside the bacterial

DRUG STUDY



INDICATIONUncomplicated UTI, otitis media, pharyngitis,

tonsilitis and bronchitis

DRUG STUDY



CONTRAINDICATIONHypersensitivity reactions such as

urticaria, rash, drug fever, erythema

multiforme

DRUG STUDY



SIDE EFFECTSDiarrhea, rash, vomiting, nausea, dizziness

DRUG STUDY



Nursing ImplicationsAssessment:Determine previous hypersensitivity

reactions to cephalosporins, penicillins and otherallergies particularly to drugs prior to initiation oftherapy

Lab tests: perform C & S test prior to initiation ofdrug therapy

Monitor for superinfections caused byovergrowth of nonsusceptible organism

particularly during prolonged useDiagnosis: Risk for infection

DRUG STUDY



Nursing Implications

Planning:Ensure patient receives the full course of cephalosporin asprescribed for the duration specified.

Advise patient to consume all the drugs even thoughsigns/symptoms may resolve earlier in the course

ImplementationProvide small frequent meals as tolerated mouth care,

ice chips if stomatitis occursProvide safety measures including safety side rails, adequatelighting and assistance with ambulation

Take medication with food if gastric irritation occurs.

EvaluationMonitor patient response to the drug regimen

Monitor for adverse effects and evaluate the effectiveness of comfortand safety measures

NURSING PROBLEMS



CUES NURSINGPROBLEM

RANK JUSTIFICATION

urticarial

rash

alteration in skin

integrity related

to side effects of

medication

secondary toallergic response

due to intake of

medication

#1 Urticarial rash, although not

life-threatening causes

extreme discomfort for the

patient

NURSING PROBLEMS



CUES NURSINGPROBLEM

RANK JUSTIFICATION

fever hyperthermia

related to

illness

#2 Health threatening in which

in which if left untreated

could lead to fever-induced

seizure in children 6 months

to 5 years old. Although

alarming for the parents, the

vast majority of seizure

cause no lasting effects.

NURSING PROBLEMS



CUES NURSINGPROBLEM

RANK JUSTIFICATION

Coughs

and colds

risk for infection

related to

inadequate

primary

defenses

#3 Health threatening in which if

left untreated could lead to

complications such as

bacterial or viral infections.

NURSING CARE PLAN



ASSESSMENTSUBJECTIVE:

- "rashes nag start sa mga paa"

OBJECTIVE: Temp: 38.8 ° C

RR: 36

BP: 90/60 PR:132

PE (+) urticarial rashes in upper and lower extremeties

NURSING CARE PLAN



DIAGNOSIS Alteration in skin integrity related to side

effects of medication secondary response

of the body to medication due to the intakeof medication

BACKGROUND KNOWLEDGEDrug related Type IV hypersensitivity is

known to cause rashes

NURSING CARE PLAN



OUTCOME/PLANNINGWithin 12 hours of nursing intervention,

the patient will display less irritability and

timely healing of skin lesion withoutcomplication

NURSING CARE PLAN



IMPLEMENTATION

INDEPENDENT: Identify underlying condition or pathology involved (allergic reaction,

burns, communicable disease, familial history) Helps identify the cause of the skin rash and focus on precise treatment

Review medication and therapy regimen (use of sulfonamide drugs,penicillin, anticonvulsant)

Helps identify the source of the rash whether a allergic response to drugtherapy

Administer local skin care for rash such as calamine lotion, coldcompresses or Burrow solution Local skin care such as cold

compresses, Calamine lotion or Burrow solution soothes rashes

NURSING CARE PLAN



IMPLEMENTATION DEPENDENT

Administer replacement fluid and electrolytes as ordered

by physician

In order to prevent dehydration and electrolyte imbalance

Administer analgesics or NSAIDs as ordered by the

physician

To prevent pain via drug therapy

COLLABORATIVE

Instruct dietician to plan hypoallergenic diet In order to prevent further allergic reactions

NURSING CARE PLAN



EVALUATIONWithin 12hours of nursing intervention, goal was

effective

efficient appropriate

adequate

acceptable

and the patient was relieved of skin irritations

NURSING CARE PLAN



ASSESSMENSUBJECTIVE:

coughs and colds

OBJECTIVE:

PE: (+) harsh breaths sounds

NURSING CARE PLAN



DIAGNOSISRisk for infection related

to inadequate primary

defenses

BackgroundKnowledge

Patient is an infant and

therefore has an

immature immune

system and has had

little time to acquire

immunity to commonviruses

NURSING CARE PLAN



OUTCOME/PLANNINGWithin 4 hours of nursing intervention, the

patient will gain knowledge of coughs and

cold as well as prevent recurrence ofcoughs and colds

NURSING CARE PLAN



Implementation INDEPENDENT:

Identify interventions to prevent or reduce risk of

infection such as hand washing In order to protect patient from potential sources of pathogen or infections

Demonstrate techniques to promote safe

environment such as avoid baby from touching

contaminated surfaces like a toy or isolate babyfrom air exposure with sick household member

NURSING CARE PLAN



Implementation DEPENDENT

Administer antibiotic drugs as prescribed

by the physician- For pharmacological intervention of infective agent

COLLABORATIVE

Instruct dietician to prepare nutritious foodhigh in Vitamins C, Vitamin E and folate To reduce risk of infection by food intervention

NURSING CARE PLAN



EVALUATIONWithin 4 hours of nursing intervention goal was

effective

efficient

appropriate

adequate

acceptable

and that the patient response to interventions,teaching and actions were acknowledge

NURSING CARE PLAN



ASSESSMENTSUBJECTIVE

intermittent fever

OBJECTIVE

PE:

Temp 38.8 ° C

Chest X-ray Impression: PPTB, bihilar

NURSING CARE PLAN



DIAGNOSISHyperthermia related to

illness

BackgroundKnowledge

Infants in the Philippine

setting are exposed to

tuberculosis bacilli

and most suffer from

primary tuberculosis

and Ghon's complex

NURSING CARE PLAN



OUTCOME/PLANNINGWithin 8 hours of nursing intervention the

patient will maintain core temperature

within normal range

NURSING CARE PLAN



Implementation INDEPENDENT:

Promote surface cooling by means of undressing, coolenvironment , tepid sponge bath, local ice packs

- To promote heat loss by evaporation and

conduction

DEPENDENT:

Administer antipyretics orally or rectally as ordered bythe physician. Refrain use of aspirin in children (Reye'ssyndrome)

- To lower fever by pharmacologic intervention

NURSING CARE PLAN



EVALUATIONWithin 8 hours of nursing intervention, goal was

effective

efficient

appropriate

adequate

acceptable

in that the patient was able to maintain normalrange core temperature

DISCHARGE PLAN



Medication

Cetirizine HCl (Zyrtec) 5 mg/ 5ml 2 ml orally, once a day before bed timefor rashes

Cefixime (Suprax) 100 mg/ 5 ml give 3 ml orally every 12 hours for 7 days

Do not skip a dose

Ensure patient receives the full course of cephalosporin as prescribed for

the duration specified. Advise patient to consume all the drugs even thoughsigns/symptoms may resolve earlier in the course

Take cefixime with food if gastric irritation occurs

Apply Calamine Lotion three times a day for rashe

Exercise

Patient should resume with usual activities of daily living Encourage patient to exercise because exercise helps keep a child maintain

a healthy weight , build healthy bones and muscles and sleep better atnights

DISCHARGE PLAN



Treatment

Reduce the itching discomfort by applying cool, moist compresses to theskin for treatment of mild erythema multiforme.

If the itching is widespread, instruct patient to take corticosteroids orantihistamines by mouth or use a topical anesthetic. Discuss options withthe patient's physician to avoid any conflict with your current medicationregimen.

Apply topical anesthetics for lesions located in the mouth. Instruct patientthat these irritating skin lesions can be relieved with over-the-countermedication. Examples include Blistex and Carmex for keeping the soresmoist and Anbesol, which contains a local anesthetic.

Health Teaching

Inform patient that erythema multiforme is self-limited and is usually caused

by infections or allergic reactions to drug therapy. Instruct patient's parents to control infection in the household to prevent

recurrence of disease such as frequent hand washing or preventing patientto play with contaminated toy

DISCHARGE PLAN



Outpatient Instruct parents of patient that erythema multiforme is a self-limiting disease and can

be treated as an outpatient.

Instruct parents of patient to seek health care provider if there is recurring infection orif outbreaks involve burning eyes, blisters on skin and mucous membranes. Informparents of patient that erythema multiforme can progress to Steven-Johnsonsyndrome, a life threatening, but rare skin disorder.

Diet

Instruct dietary plans for patient which involve food rich in Vitamin C and Vitamin E(breakfast cereals, fruits, vegetables, nuts and fish). Foods rich in Vitamin C andVitamin E reduce inflammation and boost immune response to skin disorders.

Instruct parents of patient to drink plenty of water to prevent dehydration, moisturizesand improves skin condition.

Spiritual

Advise patient the benefits of spiritual life (whether via meditation or personalreligious beliefs) which can reduce fear, anxiety and improve mental health.

REFERENCES

(1) Seeley's Essent ia l of Anatomy and Physio logy (7th ed)

Cinnamon L VanPutte Southwestern Illinois University



Cinnamon L. VanPutte, Southwestern Illinois UniversityJennifer L. Regan, University of Southern Mississippi Andrew F. Russo, University of Iowa

Mc Graw Hill ; 2010

(2) Erythema Mult i form e

Michele R. LAMOREUX, M.D., Marna R. STERNBACH, M.D.,

and W. TERESA HSU, M.D., PH.D.

Am erican Academy of FamilyPhysician .

2006 Dec 1;74(11):1883-1888.

(3) Erythema Mult i form e

Jose A. Plaza, MD July 29, 2011

emedicine.medscape. com

(4) Kaplan Medical USMLE Step 1 Lecture Notes “Pathology”

John Barone, MD 2008

(5) Kaplan Medical USMLE Step 1 Lecture Notes “Immunology” Mary Ruebush, PhD, 2008

erythema multiforme ppt (1)

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