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CASE PRESENTATION ON
GASTROENTERITIS AND ACUTE
RENAL FAILURE
BY P DEEPAK
5th year Pharm D
PATIENT DEMOGRAPHIC DETAILS
PATIENT NAME-XYZ
PATIENT AGE- 42YEARS
SEX-FEMALE
DATE 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 EVIDENCE
Pathology 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 1-0-1
Inj Ondansetron 4mg IV 1-1-1
Tab Sporolac 2-2-2
Cap Doxycycline 300mg stat
Inj Ciprofloxacin 100ml IV 1-0-1
TREATMENT CHART
DRUGS DOS
E
ROU
TE
FREQUE
NCY
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 100m
g
P.O 1-1-1 + + +
Cap
Doxycycline
300m
g
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/lit
Urine 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 1-0-1
Inj Ondansetron 4mg IV 1-1-1
Tab Sporolac 2-2-2
Cap Doxycycline 300mg stat
Inj Ciprofloxacin 100ml IV 1-0-1
TREATMENT CHART
DRUGS DOS
E
ROU
TE
FREQUE
NCY
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 100m
g
P.O 1-1-1 + + +
Cap
Doxycycline
300m
g
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

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Case presentation on gastroenteritis and acute renal failure

  • 1. CASE PRESENTATION ON GASTROENTERITIS AND ACUTE RENAL FAILURE BY P DEEPAK 5th year Pharm D
  • 2. PATIENT DEMOGRAPHIC DETAILS PATIENT NAME-XYZ PATIENT AGE- 42YEARS SEX-FEMALE DATE OF ADMISSION- 11-06-2013
  • 4. 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
  • 5. OBJECTIVE EVIDENCE Pathology report: • Stools are semisolid in nature • Mucus present greenish in colour • Entamoeba histolytica cyst seen • N: 83%(40-75%) • L: 10%
  • 6. 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:
  • 7. Assessment of current therapy- Tab Pantoprazole: 40 mg IV 1-0-1 Inj Ondansetron 4mg IV 1-1-1 Tab Sporolac 2-2-2 Cap Doxycycline 300mg stat Inj Ciprofloxacin 100ml IV 1-0-1
  • 8. TREATMENT CHART DRUGS DOS E ROU TE FREQUE NCY 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 100m g P.O 1-1-1 + + + Cap Doxycycline 300m g P.O stat + stop
  • 9. 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
  • 11. SOAP FOR ACUTE RENAL FAILURE
  • 12. SUBJECTIVE EVIDENCE • C/o loose stools and vomiting
  • 13. OBJECTIVE EVIDENCE • Urea: 73mg % • S. Cr: 3.2 mg% • Cl: 114 mmol/lit • K+: 3.2 mmol/lit • Na+: 144 mol/lit Urine 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
  • 14. 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
  • 15. Assessment of current therapy- Tab Pantoprazole: 40 mg IV 1-0-1 Inj Ondansetron 4mg IV 1-1-1 Tab Sporolac 2-2-2 Cap Doxycycline 300mg stat Inj Ciprofloxacin 100ml IV 1-0-1
  • 16. TREATMENT CHART DRUGS DOS E ROU TE FREQUE NCY 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 100m g P.O 1-1-1 + + + Cap Doxycycline 300m g P.O stat + stop
  • 17. 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
  • 18. 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
  • 19. • Food may be offered often in small amounts. Suggested foods include: • Cereals, bread, potatoes, meat • Plain yogurt, bananas, fresh apples • Vegetables