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    Clinical Case Sheet

    Uploaded by

    Inderbir Singh
    The patient presented with right flank pain and colicky pain with mild fever. Laboratory tests revealed normal renal function and liver function. The provisional diagnosis was urolithiasis. The patient was prescribed Monal, Diclofenac, Renalka syrup, Amikacin, Pantoprazole, Ticmol and Ringer Lactate solution. The rational drugs included Monal for urinary tract infection, Diclofenac for pain relief, Renalka for burning micturition, and Ringer Lactate to maintain electrolyte balance. Pantoprazole, Amikacin and Ticmol were irrational choices given the presentation.

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    Clinical Case Sheet

    Uploaded by

    Inderbir Singh
    32 views11 pages
    The patient presented with right flank pain and colicky pain with mild fever. Laboratory tests revealed normal renal function and liver function. The provisional diagnosis was urolithiasis. The patient was prescribed Monal, Diclofenac, Renalka syrup, Amikacin, Pantoprazole, Ticmol and Ringer Lactate solution. The rational drugs included Monal for urinary tract infection, Diclofenac for pain relief, Renalka for burning micturition, and Ringer Lactate to maintain electrolyte balance. Pantoprazole, Amikacin and Ticmol were irrational choices given the presentation.

    Original Description:

    Adverse drug reaction presentation

    Original Title

    Surgery

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    The patient presented with right flank pain and colicky pain with mild fever. Laboratory tests revealed normal renal function and liver function. The provisional diagnosis was urolithiasis. The patient was prescribed Monal, Diclofenac, Renalka syrup, Amikacin, Pantoprazole, Ticmol and Ringer Lactate solution. The rational drugs included Monal for urinary tract infection, Diclofenac for pain relief, Renalka for burning micturition, and Ringer Lactate to maintain electrolyte balance. Pantoprazole, Amikacin and Ticmol were irrational choices given the presentation.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    32 views11 pages

    Clinical Case Sheet

    Uploaded by

    Inderbir Singh
    The patient presented with right flank pain and colicky pain with mild fever. Laboratory tests revealed normal renal function and liver function. The provisional diagnosis was urolithiasis. The patient was prescribed Monal, Diclofenac, Renalka syrup, Amikacin, Pantoprazole, Ticmol and Ringer Lactate solution. The rational drugs included Monal for urinary tract infection, Diclofenac for pain relief, Renalka for burning micturition, and Ringer Lactate to maintain electrolyte balance. Pantoprazole, Amikacin and Ticmol were irrational choices given the presentation.

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    © All Rights Reserved
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    CLINICAL CASE SHEET

    NAME OF PATIENT : Madhu


    REGN N0. : 567173
    AGE: 29 yrs SEX : Female
    DEPARTMENT : Surgery
    WEIGHT : 54 kg
    ADDRESS : Rudraprayag

    CHIEF COMPLAINTS : The patient came to the hospital with the following
    chief complaints on 26/09/2018 at 10:24 a.m. :-
    Rt. Flank pain And colicky pain with mild fever
    The person was apparently asymptomatic when she
    first experienced pain on the right side of body and
    nausea 1 week back.

     Pain
    Sharp and sudden in onset.
    Duration- 7-8 days
    Colicky in nature
    Associated symptoms- nausea, vomiting, burning and
    frequent micturition and continuous fever
     Past Medical History-
    No significant past medical history.
     Past Surgical History-
    No past surgical history.
     Negative History:
     No history of pain abdomen.
     No history of Hypertension, DM, TB.
     Personal History
     Diet- mixed diet
     Bowel and bladder habits – normal
     Sleep- normal patterns.
     No history of smoking and alcohol addiction.
    HAEMATOLOGY
     Hb : 14.3gm/dL
    SEROLOGY
     TLC : 7200/cmm
     HBsAG-Negative
     DLC :  HIV I and II-Negative
    Polymorphs- 92%
    o Lymphocytes- 30%  HCV-Negative
    o Monocytes - 3%
    o Eosinophils- 0%
     Platelet Count : 3.90 lakh/uL
     PCV: 36.3%

    BIOCHEMISTRY
    PROVISIONAL DIAGNOSIS: UROLITHIASIS
     RENAL FUNCTION PROFILE –
    Blood Urea : 36 mg/dL
    Serum Creatinine : 0.8 mg/dL
     LIVER FUNCTION PROFILE –
    serum bilirubin(total) : 0.5mg/dL
    SGPT – 20U/L
    SGOT – 26U/L
    serum ALP - 46
    DRUG DOSE MOA REMARKS
    DICLOFENAC 75mg inj. IM Inhibits PG synthesis and is COX Provides relief from renal colic.
    2 selective
    TAMSULOSIN 0.4 mg OD orally It is a alpha 1 adrenergic blocking By it’s relaxant effect helps in easy
    agent and causes relaxation in the passage of renal stones.
    bladder .

    HYDROCHLORTHIAZIDE 25mg BD orally A thiazide diuretic that inhibit Na Cl Used to treat specifically calcium
    symport at DT stones in kidney

    ALLOPURINOL 200 mg OD orally It competitively inhibits xanthine Used in treatment of stones majorally
    oxidase and reduces uric acid consisting of uric acid
    synthesis

    ACETOHYDROXAMIC ACID 10-15mg/kg OD orally Irreversible enzyme inhibitor of the Used with antibiotics to treat bladder
    urease enzyme in various bacteria’s infections. Decreased ammonia
    prevents stone formation.

    PIPERACILLIN 6-8g iv OD A beta lactam antibiotic of Used before surgeries to prevent


    ureidopenicillin class that interferes bacterial infections
    with bacterial cell wall especially
    gram –ve bacteria.

    POTASSIUM CITRATE 10 mEq TDS orally A urine alkalizing agent that Prevents uric acid and cystine kidney
    crystallizes stone forming salts such stones from forming.
    as calcium oxalate,etc within the
    bladder.
    S.NO DOSAGE DRUGS DOSE DURATION & ROUTE
    FORM DOSE
    INTERVAL

    1. Inj. Monal 4.5gm TD i.v

    2. Inj. Amikacin 750mg OD i.v

    3. Inj. Pantop 40mg OD i.v


    4. Inj. Diclo 75mg TDS i.v
    5. Inj. Ticmol 1gm TDS i.v

    6. Syp. Renalka 2 tsf BD oral

    7. Inj. RL soln. 2 Stat iv.


    Q1. Is the name of drug written legibly? Q9. Is antibiotic prescribed or not? If yes, then name them.
    1 2 3 4 5 6 7 Yes ,
    Y Y Y Y Y Y Y inj.MONAL(PIPERACILLIN+TAZOBACTAM),AMIKACIN

    Q2. Is the strength written or not? Q10. Is patient suffering from any adverse drug reaction?
    1 2 3 4 5 6 7 NO
    N N N N N N N
    Q11. Total number of drugs prescribed?
    Q3. Is the dose of prescribed medication written? 7
    1 2 3 4 5 6 7
    Y Y YY Y Y Y Q12. Medicines used by generic and brand name :-

    Q4. Is the dosage form mentioned? Medicines used by generic name: 4


    1 2 3 4 5 6 7 1.Amikacin 2.pantop( pantoprazole)
    Y Y Y Y Y Y Y 3.Diclo( diclofenac) 4.Ringer Lactate

    Q5. Is the frequency of drug mentioned?


    1 2 3 4 5 6 7 Medicines used by brand name: 2
    Y Y Y Y Y Y Y 1. Monal (piperacillin ,tazobactam)
    2.TICMOL
    Q6. Is the route of administration mentioned? 3.Renalka
    1 2 3 4 5 6 7
    Y Y Y Y Y Y Y
    Q13. Any ayurvedic/homeopathic medicine used? Yes
    Q7. Is the abbreviation used? 1.syrup Renalka
    1 2 3 4 5 6 7
    N N Y Y N N Y
    Q8. Are all the drugs administered on time?
    1 2 3 4 5 6 7
    Y Y Y Y Y Y Y
    .
    Pros:
     Drug name is written legibly.
     Route, frequency and dosage form of all prescribed drugs are written.
    Cons:
     Strength of all prescribed drugs are not written.
    Drug combination if used: inj. Monal( piperacillin+ tazobactam)
    1.Monal( piperacillin , tazobactam)-
    Piperacillin is a ureidopenicillin active against gram negative bacteria. Tazobactam
    is a beta lactamase inhibitor. Inj monal is used for intra abdominal ,kidney and
    urinary tract infections. It’s use here is RATIONAL.

    2.Pantop( pantoprazole)-
    pantoprazole is a proton pump inhibitor used to reduce acid secretion and provide
    relief in gastic and duodenal ulcers and GERD’s. It’s use here is IRR ATIONAL.

    3. Diclo( diclofenac)-
    A analgesic, antipyretic and anti inflammatory drug. It is used to relieve renal
    colic.It’s use here is RATIONAL since the patient complains of pain.
    4. Renalka-
    Renalka is a syrup whose anti inflammatory and analgesic properties soothe the inflamed
    mucosa and alleviate the burning sensation or pain that occurs during urination. It’s use is
    RATIONAL here because the patient suffered from burning micturition.
    5. Amikacin-
    Amikacin is a broad spectrum aminoglycoside antibiotic mostly used against gram negative
    bacteria. Emperically it is used for the treatment of hospital acquired G-ve bacillary
    infection.Hence it’s use is IRRATIONAL here.
    6. Ringer Lactate solution-
    It is used to replenish body fluids and maintain electrolyte balance in body.It is also used to
    compensate blood loss caused due to trauma and surgery. It’s use is RATIONAL
    7.Ticmol (paracetamol) -
    it is commonly used for it’s antipyretic and analgesic effects. It is used in headache,
    musculoskeleton pain, migraine etc. However its use is IRRATIONAL here.
     Monal , Diclo, Renalka and Ringer lacatate are rational.

     Pantop, Amikacin and Ticmol are irrational.

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