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