CASE PRESENTATION ON GASTROENTERITIS AND ACUTE
RENAL FAILURE
BY P DEEPAK5th year Pharm D
PATIENT DEMOGRAPHIC DETAILS
PATIENT NAME-XYZPATIENT AGE- 42YEARSSEX-FEMALEDATE OF ADMISSION- 11-06-2013
SOAP FOR GASTROENTERITIS
SUBJECTIVE EVIDENCE
• C/o several episodes of loose stools since 3 days
• C/o several episodes of vomiting since one day• H/o spasmodic type of abdominal pain
OBJECTIVE EVIDENCEPathology report:• Stools are semisolid in nature• Mucus present greenish in colour• Entamoeba histolytica cyst seen• N: 83%(40-75%)• L: 10%
From subjective and objective evidence, it has been diagnosed as Acute Gastroenteritis.
THERAPEUTIC GOALS:Patient specific:- To prevent dehydration by making sure the body has
enough water and fluids.Disease specific:- to prevent recurrence of disease
ASSESSMENT:
Assessment of current therapy-Tab Pantoprazole: 40 mg IV 1-0-1Inj Ondansetron 4mg IV 1-1-1Tab Sporolac 2-2-2Cap Doxycycline 300mg statInj Ciprofloxacin 100ml IV 1-0-1
TREATMENT CHART
DRUGS DOSE
ROUTE
FREQUENCY
DAY1 DAY2 DAY3
Inj Ciprofloxacin
100ml IV 1-0-1 + + stop
Inj Metronidazole
100ml IV 1-1-1 + + stop
Inj Pantoprazole 40mg IV 1-0-1 + + Tab Pantoprazole
Inj Ondansatron 4mg IV 1-1-1 + + 1-0-0/sos
T Sporolac 2-2-2 + + +
T Racecadotril 100mg
P.O 1-1-1 + + +
Cap Doxycycline
300mg
P.O stat + stop
DAY PROGRESS
1 C/O6-7 episodes of loose stools ,C/o nausea.No H/o vomiting/abdominal pain.PR: 84/min,BP:124/76mm Hg
2 Vomitings and loose stools reduced ,No abdominal pain ,BP: 124/76mm Hg,PR: 82 bpm
4 Patient comfortable
PROGRESS CHART
MONITORING PARAMETERS-
LABORATORY PARAMETERS-
SOAP FOR ACUTE RENAL FAILURE
SUBJECTIVE EVIDENCE
• C/o loose stools and vomiting
OBJECTIVE EVIDENCE• Urea: 73mg %• S. Cr: 3.2 mg%• Cl: 114 mmol/lit• K+: 3.2 mmol/lit• Na+: 144 mol/litUrine analysis:• RBC: 1-2/hpf• Pus cells: 2-4/hpf• Alb : traces• Epithelial cells: 4-6/hpf• Stools: semisolid containing greenish mucus• Entamoeba cyst seen
ASSESSMENT
From subjective and objective evidence, it has been diagnosed as Acute renal failure
THERAPEUTIC GOALS:Patient specific:- To prevent dehydration by
making sure the body has enough water and fluids.
Disease specific:- to prevent recurrence of disease
Assessment of current therapy-Tab Pantoprazole: 40 mg IV 1-0-1Inj Ondansetron 4mg IV 1-1-1Tab Sporolac 2-2-2Cap Doxycycline 300mg statInj Ciprofloxacin 100ml IV 1-0-1
TREATMENT CHART
DRUGS DOSE
ROUTE
FREQUENCY
DAY1 DAY2 DAY3
Inj Ciprofloxacin
100ml IV 1-0-1 + + stop
Inj Metronidazole
100ml IV 1-1-1 + + stop
Inj Pantoprazole 40mg IV 1-0-1 + + Tab Pantoprazole
Inj Ondansatron 4mg IV 1-1-1 + + 1-0-0/sos
T Sporolac 2-2-2 + + +
T Racecadotril 100mg
P.O 1-1-1 + + +
Cap Doxycycline
300mg
P.O stat + stop
DAY PROGRESS
1 C/O6-7 episodes of loose stools ,C/o nausea.No H/o vomiting/abdominal pain.PR: 84/min,BP:124/76mm Hg
2 Vomitings and loose stools reduced ,No abdominal pain ,BP: 124/76mm Hg,PR: 82 bpm
4 Patient comfortable
PROGRESS CHART
Patient counseling points
• THINGS TO AVOID WHILE RECOVERING:• Alcohol• Caffeine• Dairy products• Citrus products• Fatty, greasy and/or fried foods• Raw fruits and vegetables• Aspirin• Ibuprofen
• Food may be offered often in small amounts. Suggested foods include:
• Cereals, bread, potatoes, meat• Plain yogurt, bananas, fresh apples• Vegetables