It may serve the academic needs of medical & pharmacy students

1. G.MAHESH
PHARM-DVI YEAR
11-1-2014

2.  SUBJECT:
A 33 years old female patient was admitted in the
hospital on 1/1/2014 with c/o abdominal pain * 1
week{more in lower abdomen}.
 H/O vomiting is present{3-4episodes}
 H/O of burning urination.
 H/O of fever*2 days, high grade intermittent not
associated with chills.
 H/O of cough and cold is present

3.  Normal menstural cycle.
 Normal diet habbits.
 Past medical history is nil.
 OBJECTIVE:
The patient was found to be conscious and
oriented.
• The patient was febrile; No pallor / ictures ; hydration was
found to be fair
• Pulse rate:104/min
• BP:130/80mmhg

4.  Cvs: S1 S2 +
 Rs: BAE +
 P/A: Soft
 LEFT iliac fossa tenderness
 On investigation HB was found to be 12.2 gm/dl
 Total count:7,900 cu/mm
 Dc : P – 56% ;L-36% ; E- 8%
 Pcv – 36%
 Bleeding time- 2’,05” ; Clotting time- 3’,o5”

5.  Blood urea: 22 mgs
 ASSESMENT:
Based on the physical and on examinations and
investigations the patient was diagonised to have UTI ;
RENAL CALCULI ; GERD.
• TREATMENT PLAN: The goal of treatment to cure the
symptoms of the disease and infection.
• Patient was treated with IV fluids

6. S.N DRUGS DOSE R.O.A FREQ 6 7 8 9
1 INJ. CIPRO 200mg IV BD * * * *
2 INJ. METRO 500mg IV BD * * * *
3 TAB. PARA 500mg P/O TDS * * * *
4 TAB . DICYCLOMINE P/O BD * * * *
5 TAB. DOMSTAL 10mg P/O BD * * * *
6 SYP ANTACID 5ml P/O TDS * * * *
7 INJ . RANTAC 2cc IV BD * * * *

7.  Apart from that syrup ALEX is given for cough.
• Patient counselling:
o Drink a lot of fluids, such as herbal teas and water. Avoid
sweetened fruit juices and other sweetened drinks.
o Cranberries and blueberries contain substances that inhibit
the binding of bacteria to bladder tissue.
o Eat antioxidant-rich foods, including fruits (such as
blueberries, cherries, and tomatoes), and vegetables (such
as bell peppers).Eat more high fiber foods, including
beans, oats, root vegetables (such as potatoes and yams)

8. o Taking showers instead of baths helps prevent bacteria
from entering the urethra and causing a UTI.
o Use clean cloths and eat hygiene food.
o Clean your bath rooms properly to prevent the infection.