Date:
Patient:
** admitting diagnosis:** Stevens-Johnson Syndrome (SJS)
History of Present Illness:
Briefly summarize the patient’s presentation, including:
Date of symptom onset
Initial symptoms (fever, malaise, sore throat, etc.)
Development of rash (timing, location, progression)
Mucous membrane involvement (eyes, mouth, genitals)
Medications potentially associated with SJS (start date, dose)
Any prior history of SJS or similar reactions
Physical Exam:
Describe the current extent and severity of the rash:
Body surface area involved
Characteristics of the rash (macules, papules, vesicles, bullae, desquamation)
Mucous membrane involvement (oral, ocular, genital)
Vital signs (temperature, heart rate, blood pressure, respiratory rate)
Labs:
List relevant laboratory findings:
CBC (complete blood count) with differential
Electrolytes
Liver function tests
Renal function tests
Blood cultures (if indicated)
Imaging:
Mention any relevant imaging studies performed (chest X-ray, etc.)
Diagnosis:
State the current diagnosis (e.g., SJS, SJS with suspected medication causality)
Management:
Summarize the current treatment plan:
Discontinuation of suspected culprit medication(s)
Skin care measures (wet dressings, emollients)
Pain management
Mucosal care (oral rinses, eye lubricants)
Fluid resuscitation (if needed)
Nutritional support
Infection prophylaxis
Consultation:
Document any consultations with specialists (dermatology, ophthalmology, etc.)
Plan:
Outline the plan for the next day(s):
Monitoring of vital signs and fluid balance
Pain management
Wound care
Nutritional assessment
Repeat laboratory tests (as needed)
Consideration for ophthalmology consult (if ocular involvement)
Discharge planning (once stable)
Prognosis:
Briefly discuss the prognosis based on disease severity and response to treatment
Note: This is a template and should be adapted to the specific needs of each patient.
Additional Information:
You may also want to include sections for:
Social history (smoking, alcohol use)
Allergies
Family history