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He further submitted that, Steven Johnson Syndrome is a very serious allergic skin condition which progressed in this patient to Toxic Epidermal Necrolysis (TEN) and it is usually life threatening condition where mortality (death) is not uncommon. The hospital and its doctors had repeatedly and regularly explained the serious condition of patient to her relatives and that's why she was shifted to Intensive Care Unit of the hospital on 22.9.2008.

 

7.       We have perused the medical record of OP-4 hospital.  It is clearly   shows that, at the time of admission, patient had itching, rashes on the upper abdomen and difficulty in swallowing.  Dr. Adwait Patil, OP 1 provisionally diagnosed the patient as PUO (Pyrexia of unknown origin), ? drug reaction ? Steven Johnson Syndrome. On admission, patient was administered antibiotic- Monocef, Inj. Omaz, and Tab. Calpol.  Patient was seen by Dr. Pawar and clinically noted that,there was swelling on the eyes and high grade fever of 104° F. Patient showed puffiness of face, swollen eyes, watery discharge, Oral cavity - chapping, ulceration.  There was target lesion, trunk palm noted.  The patient was treated with dilute H2O2 thrice a day.  Advised to wash eyes with saline, also to do oral gargle with dilute KMnO4 (Condy's Gargle) thrice a day. Patient was also given smaller doses of steroids inj. Dexa 8 mg and antihistaminic inj Avil and also advised Betadine Ointment.  Further,OP-1 advised investigations for Dengue, Malaria, Widal, Blood culture, urine culture and skin biopsy.  On 17.9.2008, patient had pain in throat and difficulty in swallowing, there was no new lesion. The patient was regularly followed by Dr. Pawar. On 18.9.2008, the patient had complaints of redness of eyes but no new lesion; blisters were present on the trunk and chest, fever present. The patient's urinary ketone bodies test was positive and there was albuminuria. On 19.9.2008, the burning on chest, abdomen and back increased, mouth ulcers increased.  On that day, there was development of new lesions on Soles, Blister ++.  It was advised not to give any antibiotics as there was no temperature.  It was also advised Syrup Crocin SOS if temp > 100° F.  The patient was examined by Dr. Maniar on 19.9.2008 for the ocular examination.  It was found that lid and lashes were normal.  There was minimal congestion, hence eye drops were advised in between 2-4 p.m. It is contended that,  on 20.9.2008, the patient has taken Crocin Syrup on her own without informing any doctor at 11.00 a.m.  Dr. Maniar examined the patient on 20.9.2008 and noted congestion, and eye lid was in same position and called up for follow up on Monday.  On the 21.9.2008, Dr. Pawar noticed new lesions  again developed, erosions + eyelid + tip of the nose, soles - Erythematous spots ++ and it was suspected that patient may be reacting to Paracetamol. The patient had 103 ° F temperature.  Dr. Pawar advised inj. Azee 1 gm, IV BD and paracetamol.  Counsel for patient contended that despite suspecting reaction, again Paracetamol was advised.  Subsequently, the patient had difficulty in deglutition.  Thereafter, Dr. Pawar on 22.9.2008 noted erosions of the upper eyelid, lower eyelid, therefore suspected that the patient was going into Toxic Endodermal Necrosis (TEN). They were unable to explain the cause of fever. Dr. Pawar again asked to refer Dr. Adwait Patil for cause of fever.  Thereafter, as per the advice of Dr. Pawar, the patient was advised to shift to ICCU.  Dr. Rajiv Soman, senior physician was called.  He also diagnosed TEN and advised to continue steroids, anti-histaminics, IV fluids and SOS Cyclosporine.  He withheld the inj. Azee.  Dr. Maniar, Ophthlmologist also examined the patient on 22.9.2008.  It was noticed that lesions falling of rest are normal.  The patient was advised to put the RT but it was not possible.  On 22.9.2008, maximum liquids, gargle, eye care was advised KMNO4 and saline wash was advised.  Also, it was advised to ask Dr. Soman about giving IV antibiotics as a daily review.  On 23.9.2008, the patient was examined by Dr. Aruna, who also noted the same findings.