CASE PRSENTATION

1. Case on UTI and Myoclonic
Jerks
R.Anusha
Pharm D VI Year
Roll No:170514882007.

2. Patient Name:Ms.AR
Gender:Female
Age:23 years
IP No:315720
DOA:28/8/19
DOD:31/8/19

3. SUBJECTIVE
• Chief Complaints: Fever with chills
• Present Illness History: Fever with chills since 1 week, H/o
loose stools for 3 days present.
• Past medical/medication history:
Outside labs- CBC:WNL,CUE:12 pus cells,CRP:132.
Was started on oral antibiotic in OPD basis.
K/C/o Myoclonic jerks since 5 years.
(on T.KEPPRA 500 mg OD)
H/o UTI(June 2019), Cultures:E.Coli (was on Doxy and
Levofloxacin).
• Allergies: NKDA.

4. OBJECTIVE
PHYSICAL APPEARANCE:
Height: 144.78cms
Weight: 50 kgs
B.M.I: 23.85 kg/m2.
VITALS:
Patient alert, conscious
B.P: 100/60 mmHg.
R.R: 22 breaths/min.
P.R: 123 beats/min.
Temperature: 1020F

5. Diagnostic test:
• Hb:10.8 gm
• TLC:8.3
• Platelets:4.3 Lakh
FINAL DIAGNOSIS: C/o UTI ,
K/C/o Myoclonic jerks
Widal:Negative
Blood for Malarial Parasite:Negative
ESR:52
Dengue NS 1:Negative

6. DRUG CHART
Brand Generic Dose ROA Freq. Category Indication
IVF NS
28/8/19 - 31/8/19
Normal saline 100 ml/hr IVF Onflow Electrolyte Hydration
Inj.TAMIN
given on
28/8/19
Paracetamol 500 mg IV STAT Antipyretic Fever
Inj.ZOSTUM
Started on
28/8/19 and
continued
Ceftazidine 1.5 gm IV BD Antibiotic UTI
T.CALPOL
Started on
29/8/19 and
continued
Paracetamol 650 mg PO QID Antipyretic Fever
T.KEPPRA
As per home
medication
Levitiracetam 500 mg PO OD
(After
Dinner)
AED Myoclonic
jerks
T.LEON
Started on
30/8/19 and
continued
Levofloxacin 750 mg PO OD Antibiotic UTI

7. Goals of the Treatment
• Treatment is aimed at relieving symptoms.
• To prevent recurrent infections.
• To improve quality of life.

8. ASSESSMENT
• Ms.AR ,23 YOF k/c/o epilepsy presented with complaint of
fever and loose stools.
• Relevant lab investigations were done which showed Anemia,
ESR 52, Blood for Malarial Parasite:Negative, Widal:Negative.
• She was treated with IV Fluids, Emperical antibiotics,
Antipyretics, Antiepileptics and other supportive drugs.

9. • Blood cultures showed no growth, Urine cultures showed no
growth, Fever spikes reduced.
• Patient clinically better and is being discharged in stable
condition.

10. PLAN
MONITORING PARAMETERS:
• Watch for fever spikes
• Monitor blood culture and urine culture

11. DISCHARGE MEDICATIONS:
 T.KEPRA 500 mg 1 tab to be taken orally once daily after
dinner to be continued for seizures.(AED).
T.CALPOL 650 mg 1 tab to be taken orally after food if
necessary.
T.LEON 750 mg 1 tab to be taken orally once daily after
food for 7 days given as antibiotic.
Inj.ZOSTUM 1.5 gm to be taken intravenously twice daily
after food for 2 days given as antibiotic.
T.PAN 40 mg 1 tab to be taken orally before breakfast for 1
week given for acid prophylaxis.
Review after 3 days in OPD.