The document describes a 67-year-old male patient presenting with dyspnea, constipation, anorexia, abdominal pain and headache. Examination finds the patient semiconscious and oriented with abdominal discomfort and tender abdomen. Laboratory investigations show abnormal renal function, electrolyte imbalance and signs of infection. The patient is diagnosed with septic shock with acute renal failure of unknown etiology. Treatment includes antibiotics, diuretics, bronchodilators and corticosteroids to address infection, fluid overload and organ dysfunction with the goals of improving quality of life and preventing further health complications.

1. ISOSEPTIC
SHOCK
RIDDHI PAWASKAR
(Pharm D IVth year)

2. SUBJECTIVE DATA
NAME: QRS AGE: 67 SEX: M Weight: 65 kg Height: 188cms
DOA: 21/10/19
� CHIEF COMPLAINTS:
i. Dyspnea
ii. Constipation
iii. Anorexia
iv. Abdominal pain
v. Headache
ISOSEPTIC SHOCK-Riddhi
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3. OBJECTIVE DATA
� MEDICAL H/O: Herpes-Zoster No h/o DM,HTN
� MEDICATION H/O: 3 haemodialysis done
▪ [Redicate Clav]Cefixime (200 mg) + Clavulanic Acid
(125 mg)
▪ [Tb Soft Cold] Chlorpheniramine maleate 2 MG
+Paracetamol 125 MG +Phenylephrine 5 MG
▪ [Rabepraz] Rabeprazole 10 MG
� SOCIAL H/O: Married, Farmer
� FAMILY H/O: N/S
� PREVIOUS ALLERGIES: N/S
ISOSEPTIC SHOCK-Riddhi
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4. PHYSICAL EXAMINATION
GENERAL: stable
VITALS: BP-140/90 Pulse: 130/min SpO2: % RR: /min
HEENT: N
CVS: N
CNS: semiconscious, oriented
GIT: discomfort, tender,palpated
GU: N
EXT: Left ankle area – dry wound ++
ISOSEPTIC SHOCK-Riddhi
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5. Lab investigations: CBC
D1 D3 D5
Hb(12-
16g/Dl)
12.3 9.9 11.9
RBC(4-5.5
10^12/L)
4.32 27.1 4.10
WBC(4-
10)10^9/L
16.36 24.70 15.91
NEUT (2-
7)10^9/L
15.35 22.17 14.34
LYM(0.8-
4)10^9/L
0.5 0.89 0.69
PLT (100-
450)10^3/uL
37 162 33
ISOSEPTIC SHOCK-Riddhi
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6. Lab investigations
P.S EXAM
❖ WBC: Neutrophilic
leukocytosis
❖ RBC: hypochromic+,
microcytic+, anisocytosis+
❖ PLT: decreased on smear;
no evidence of MP
SERUM ELECTROLYTES
D1 D2 D3
S. Na 114 117 125
S.K 5.7 5.9 5.9
ISOSEPTIC SHOCK-Riddhi
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7. Lab investigations
Routine Analysis
▪ S.BUN- 69.0mg/dL (5-25mg/dL)
▪ S.Creat- 5.6mg/dL (0.8-1.4mg/dL)
▪ SGPT- 29.4 U/L (upto 40 IU/L)
▪ D.Bil- 1.5 mg/dL(0-0.4mg/dL)
▪ I.Bil- 1.80 mg/dL(0.4-1.3mg/dL)
▪ T.Bil-3.30mg/dL(mg/dL)
▪ ALP- 236.7IU/L (60-170 IU/L)
▪ S.Alb- 2.2g/dL(3.8-5 g/dL)
▪ S.Glob-2.2g/dL(2.3-3.5g/dL)
▪ T.Prot: 4.4g/dL (6-8 g/dL)
▪ Procalcitonin:56.8 ng/ml (0.15-
0.50 ng/Ml)
▪ RBG: 116 mg/dL(60-120 mg/dL)
ABG
▪ pH-7.27
▪ pCO2- 28 mm Hg
▪ pO2- 88 mm Hg
▪ HCO3- 12.9mmol/L
▪ TCO2- 13.8mmol/L
▪ Beb- -12.6mmol/L
▪ BEecf- -14.0mmol/L
ISOSEPTIC SHOCK-Riddhi
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8. Lab investigations:
URINALYSIS
� SUGAR: Nil
� ALBUMIN: +ve
� 80-90 pus cells
with 1-2 RBCs
USG
� Both kidneys enlarged in size
with grade II raised cortical
echogenicity
� ARF
� Mild hepatomegaly
� Mild splenomegaly
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9. Lab investigations
STRESS TEST
� 0.84 kms( 11 mins)
� Max HR: 146 bpm
� Max BP: 164/90
� Mild ST Depression
� Negative for
exercise induced
cardiac ischemia
C-XR
� Normal chest
radiograph.
� No significant
findings
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10. Lab investigations
Leptospira
� IgM: -ve
� IgG: -ve
HbsAg & HIV tridot
� NEGATIVE
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11. ASSESSMENT
❖ FINAL DIAGNOSIS: ISOSEPTIC SHOCK WITH ARF
❖ ETIOLOGY: UNKNOWN
❖ GOALS OF THERAPY:
I. To increase quality of life
II. Prevent comorbidity, mortality & further
progression of disorder
III. Reduce adverse events of current therapy and
optimize therapy
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12. PAN 40 mg IV OD(D1-D3)
¤ Generic– Pantoprazole
¤ Category- Proton pump inhibitor
¤ MOA–It is a proton pump inhibitor,inhibits H,K ATPase enzyme
which secretes HCl in parietel cells of stomach
¤ Indications-Ulcers and reflux oesophagitis,GERD,Zollinger-Ellison
syndrome
¤ Contraindication- Hypersensitivity
¤ Side effects- Headache, diarrhea, dizziness
¤ Pregnancy–US FDA pregnancy category Not Assigned:This drug is
only recommended for use during pregnancy when there are no
alternatives and the benefit outweighs the risk.
¤ Warnings–Prolonged treatment (greater than 24-36 months) may
cause vitamin B12 deficiency.
¤ Std. Dose–20-80 mg/day
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13. EMESET 4mg IV BD(D1-D3)
¤ GENERIC: Ondansetron
¤ CATEGORY- Anti emetic
¤ MOA: Ondansetron is a selective 5-HT3-receptor antagonist which blocks serotonin,
both peripherally on vagal nerve terminals and centrally in the chemoreceptor
trigger zone
¤ INDICATIONS: CINV, Post operative nausea/vomitting,pregnancy associated nausea,vomitting.
Gastric pareisis
¤ CONTRAINDICATIONS: Hypersensitivity, concomitant use with apomorphine
¤ ADVERSE EVENTS: confusion, dizziness, fever, fatigue, gastric pain
¤ PREGNANCY: US FDA pregnancy category: B
¤ STD. DOSE: recommended dose: 0.15 mg/kg IV, with the first dose (infused over 15
minutes) 30 minutes before the start of emetogenic chemotherapy and subsequent
doses given 4 and 8 hours after the first dose.
-Maximum dose: 16 mg per dose
ISOSEPTIC SHOCK-Riddhi
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14. INJ DERIPHYLLN 1amp STAT &
OD(D1-D3)
¤ GENERIC: Etophylline (84.7mg) + Theophylline( 25.3mg)
¤ CATEGORY- Bronchodilator
¤ MOA: smooth muscle relaxation (ie, bronchodilation) and suppression of the response
of the airways to stimuli (ie, non-bronchodilator prophylactic effects). Bronchodilation
is mediated by inhibition of two isoenzymes, phosphodiesterase (PDE III and, to a
lesser extent, PDE IV)
¤ INDICATIONS: asthma, bronchitis, COPD,bradycardia
¤ CONTRAINDICATIONS: allergy, Hypersensitivity to xanthine derivatives; coronary artery
disease (where cardiac stimulation might prove harmful); peptic ulcers;
coadministration with ephedrine in children.
¤ ADVERSE EVENTS: acid base imbalance, irregular heartbeat, persistent vomitting,diuresis,
¤ PREGNANCY: US FDA pregnancy category C
¤ STD. DOSE: Initial dose: 200 mg per day given as evenly divided doses every 6 to 8
hours
After 3 days, if starting dose was tolerated: 100 mg per day given as evenly divided
doses every 6 to 8 hours
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15. INJ LASIX 10mg IV stat(D1)
¤ GENERIC: FUROSEMIDE
¤ CATEGORY- Diuretic
¤ MOA: Primarily inhibits reabsorption of sodium and chloride in the ascending loop of
Henle and proximal and distal renal tubules, interfering with the chloride-binding
cotransport system, thus causing its natriuretic effect
¤ INDICATIONS: Management of edema associated with heart failure, cirrhosis of the liver
(ie, ascites), or renal disease (including nephrotic syndrome); acute pulmonary
edema.
¤ CONTRAINDICATIONS: Hypersensitivity to sulfonamide-derived drugs; complete renal
shutdown; hepatic coma and precoma; uncorrected states of electrolyte depletion,
hypovolemia, dehydration, hyperbilirubinemiaor hypoten
¤ ADVERSE EVENTS: electrolyte depletion, painful urination, syncope, SIADH
¤ PRECAUTIONS: Furosemide is a potent diuretic which, if given in excessive amounts, can
lead to a profound diuresis with water and electrolyte depletion.
¤ PREGNANCY: US FDA pregnancy category C
¤ STD. DOSE: Initial dose: 20 to 40 mg IV (slowly over 1 to 2 minutes) or IM once; may
repeat with the same dose or increase by 20 mg no sooner than 2 hours after the
previous dose until the desired diuretic effect has been obtained.
Maintenance dose: Administer the dose that provided the desired diuretic effect
once or twice a day. ISOSEPTIC SHOCK-Riddhi
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16. INJ MONTAZ 1g iv BD(D1-
D3)
¤ GENERIC: Ceftriaxone(1000mg) + Tazobactam(125mg)
¤ CATEGORY: Bactericidal,Cephalosporin
¤ MOA: Inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-
binding proteins (PBPs)
¤ INDICATIONS: Pyelonephritis, noscomical pneumonia, UTI,
¤ CONTRAINDICATIONS: hypersensitivity to ceftolozane/tazobactam,
piperacillin/tazobactam, other members of the beta-lactam class
¤ ADVERSE EVENTS: Fever, irregular heartbeat, dizziness, abdominal pain
¤ PREGNANCY: US FDA pregnancy category Not Assigned
¤ STD. DOSE: 1.5 g IV every 8 hours
Duration of therapy: 7 days
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17. INJ BUSCOPAN 1g IV
STAT(D1)
¤ GENERIC: Hyoscine Butylbromide, Scopolamine
¤ CATEGORY: Anticholinergic Agent
¤ MOA: blocks the action of acetylcholine at parasympathetic sites in smooth muscle,
secretory glands and the CNS; increases cardiac output, dries secretions, antagonizes
histamine and serotonin; at usual recommended doses, causes blockade of
muscarinic receptors at the cardiac SA-node and is parasympatholytic
¤ INDICATIONS: Motion sickness, treatment of smooth muscle spasm of the genitourinary or
GI tract,adjunct to anaesthesia
¤ CONTRAINDICATIONS: Untreated narrow-angle glaucoma; megacolon, prostatic
hypertrophy with urinary retention; stenotic lesions or mechanical stenosis of the GI
tract; myasthenia gravis; tachycardia, angina, heart failure; paralytic or obstructive
ileus; IM administration in patients receiving anticoagulant therapy
¤ ADVERSE EVENTS: drowsiness and xerostomia, dilation of pupils,migraine, cycloplegia
¤ PREGNANCY: US FDA pregnancy category: C
¤ STD. DOSE: IM, IV, SubQ: 10 to 20 mg; maximum: 100 mg/day
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18. HYDROCORTISONE 100mg 1amp iv
STAT(D1)
¤ CATEGORY: Corticosteroid, Systemic
¤ MOA:May depress the formation, release, and activity of endogenous chemical
mediators of inflammation (kinins, histamine, liposomal enzymes, prostaglandins)
through the induction of phospholipase A2 inhibitory proteins (lipocortins) and
sequential inhibition of the release of arachidonic acid. Hydrocortisone has low to
intermediate range potency (dosage-form dependent).
¤ INDICATIONS: immune thrombocytopenia, warm autoimmune hemolytic anemia),
allergic, gastrointestinal (eg, Crohn disease, ulcerative colitis), inflammatory,
neoplastic, neurologic (eg, multiple sclerosis), rheumatic (eg, antineutrophil
cytoplasmic antibody-associated vasculitis, dermatomyositis/polymyositis, gout
[acute flare], mixed cryoglobulinemia syndrome, polyarteritis nodosa, rheumatoid
arthritis, systemic lupus erythematosus), and/or autoimmune origin.
¤ CONTRAINDICATIONS: systemic fungal infection,hypersensitivity, ITP
¤ ADVERSE EVENTS: Pancreatitis, HTN, Weight loss, seizures, eosinophilia
¤ PREGNANCY: US FDA pregnancy category: C
¤ STD. DOSE: 80 to 100 mg IM once a week for 1 to 4 week
ISOSEPTIC SHOCK-Riddhi
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19. INJ DOXY 100MG iv OD(D1-
D3)
¤ GENERIC: Doxycycline,
¤ CATEGORY:Antibiotic, Tetracycline Derivative
¤ MOA: Inhibits protein synthesis by binding with the 30S and possibly the 50S ribosomal
subunit(s) of susceptible bacteria; may also cause alterations in the cytoplasmic
membrane
¤ INDICATIONS: Treatment of infections caused by Escherichia coli, Enterobacter
aerogenes, Shigella spp., Acinetobacter spp., Klebsiella spp. (respiratory and urinary
infections), and Bacteroides spp.; Neisseria meningitidis (when penicillin is
contraindicated), STDs, Skin and skin structure infections
¤ CONTRAINDICATIONS: Use in infants and children <8 years of age or during second or
third trimester of pregnancy; breast-feeding, Hypersensitivity
¤ ADVERSE EVENTS: Benign intracranial hypertension resulting in permanent loss of
vision, superficial tooth discoloration, Bronchospasm, photosensitivity,
Hyperpigmentation, Hypoglycemia
¤ PREGNANCY: US FDA pregnancy category: D
¤ STD. DOSE: Initial dose: 200 mg orally on the first day, given in 2 divided doses (100 mg
every 12 hours)
-Maintenance dose: 100 mg orally once a day OR 50 mg orally every 12 hours
---More severe infections: 100 mg orally every 12 hours EPTIC SHOCK-Riddhi
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20. CAP ACOGUT 100mg BD(D1-
D3)
¤ GENERIC: Acotiamide
¤ CATEGORY: an acetylcholinesterase inhibitor.
¤ MOA: Cholinesterase inhibitors block the action of the enzyme cholinesterase, which is
responsible for breaking down acetylcholine. This increases levels of acetylcholine in
the synaptic cleft
¤ INDICATIONS: treatment of postprandial fullness, upper abdominal bloating, and
early satiation due to functional dyspepsia
¤ CONTRAINDICATIONS: NOT KNOWN
¤ ADVERSE EVENTS: constriction of the pupils in the eyes, increased secretion of sweat,
saliva and tears, slow heart rate, mucus secretion in the respiratory tract and
constriction of the airways.
¤ PREGNANCY: US FDA pregnancy category: not assigned
¤ STD. DOSE: 100-200 mg/day
ISOSEPTIC SHOCK-Riddhi
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21. SYP ULGEL 2tsp TDS(D2-D3)
¤ GENERIC: Magaldrate + Semithicone
¤ CATEGORY: Antiflatulent
¤ MOA: Decreases the surface tension of gas bubbles thereby disperses and prevents
gas pockets in the GI system
¤ INDICATIONS: dyspepsia, gastrointestinal discomfort, bloating, discomfort of GI region
¤ CONTRAINDICATIONS: Hypersensitivity
¤ ADVERSE EVENTS: Pruritis, constipation
¤ PREGNANCY: US FDA pregnancy category: Not formally assigned to a pregnancy
category.
¤ STD. DOSE:1 to 2 teaspoonfuls after meals and at bedtime
ISOSEPTIC SHOCK-Riddhi
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22. SYP CREMAFFIN 1tsp HS(D1-
D3)
¤ GENERIC: liquid paraffin (1.25 ml), magnesium hydroxide or milk of magnesia (3.75 ml)
and sodium picosulfate (3.33 mg)
¤ CATEGORY: Laxative
¤ MOA: Promotes bowel evacuation by causing osmotic retention of fluid which
distends the colon with increased peristaltic activity; reacts with hydrochloric acid in
stomach to form magnesium chloride
¤ INDICATIONS: Constipation, improper bowel movement, colonoscopy
¤ CONTRAINDICATIONS: Anorexia Nervosa, Diarrhoea, pregnancy, lactation
¤ ADVERSE EVENTS: fatigue, Dizziness , Diarhhoea, Cramps, and stomach aches, anorexia
¤ PREGNANCY: US FDA pregnancy category: Not formally assigned to a pregnancy
category.
¤ STD. DOSE: 3600 to 7200 mg (as magnesium hydroxide) orally per day, given once a
day in divided doses, or as directed
-Maximum dose: 7200 mg/day
-Duration of therapy: Up to 7 days
ISOSEPTIC SHOCK-Riddhi
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23. INJ CALCIUM GLUCONATE 1g OD(D1-D3)
¤ CATEGORY: Calcium supplement,replacement
¤ MOA: Moderates nerve and muscle performance via action potential threshold
regulation
¤ INDICATIONS: Dietary calcium supplementation, CCB overdose
¤ CONTRAINDICATIONS: Hypercalcemia; concomitant use of IV calcium gluconate with
ceftriaxone in neonates (≤28 days of age)
¤ ADVERSE EVENTS: weakness, confusion, feeling tired, headache, upset stomach ,
vomitting, constipation, or bone pain.
¤ PREGNANCY: US FDA pregnancy category: Not assigned
¤ STD. DOSE: Initial dose: 1000 to 2000 mg intravenously (IV)
Subsequent doses (as needed):
-IV bolus: 1000 to 2000 mg every 6 hours
-Continuous IV infusion: Initiate at 5.4 to 21.5 mg/kg/hour
Maximum IV bolus infusion rate: 200 mg/min ISOSEPTIC SHOCK-Riddhi
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24. Aloe vera juice 20ml
daily(D1-D3)
¤ MOA: unknown
¤ INDICATIONS: to inhibit infection and promote healing, sunburn, eczema
¤ CONTRAINDICATIONS: Ingestion is contraindicated in women who are pregnant or
breast-feeding, children younger than 12 years of age, and elderly patients with
suspected intestinal obstruction
¤ ADVERSE EVENTS: mild itching or burning
¤ PREGNANCY: Cathartic, reputed abortifacient.
¤ STD. DOSE: topical- max 500mg
ISOSEPTIC SHOCK-Riddhi
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25. ISOSEPTIC SHOCK-Riddhi
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26. ✔ Add Title
✔ Add Title
✔ Add Title
✔ Add Title
✔ Add Title
✔ Add Title
PATIENT NAME: XYZ HOSP. NO:
AGE: yr WEIGHT: kg
SEX: M/F:Male
DATE OF ADMISSION: 11 /02/18
DATE OF DISCHARGE: 14/02/18
COMPLAINTS ON ADMISSION :
∙
MEDICAL HISTORY :
MEDICATION HISTORY : -
SOCIAL HISTORY:
FAMILY HISTORY: NS
PREVIOUS ALLERGIES: N/S
PHYSICAL EXAMINATION: moderately build and nourished, conscious
and co-operative
GENERAL - no P I C C L E
VITAL SIGNS - PR: 90 /min ; BP : 110/80mmhg, R.R:- N/A,
HEENT - N/S
CVS - S1 S2 heard; no murmurs
RS - N/S
GIT - N/S
GU - N/S
EXT - reflexes were normal.
CNS - conscious and oriented
PROVISIONAL DIAGNOSIS:
ROUTINE BIOCHEMICAL INVESTIGATIONS HAEMATOLOGY:
Urea: mg/dl
S.Cr :mg/dl
Na: mEq/L
K: mEq/L
FBS:
PPBS:
RBS:
Tch :
TGs :
T Bili:
D Bili:
T. Prot:
Al
b:
Gl
ob
:
AS
T:
AL
T:
AL
P:
RBC : Retics:
WBC: Hb:
N: PCV:
L: MCV:
M: MCH:
E: MCHC:
B: ESR:
Platelets:.
URINE ANALYSIS OTHERS
pH: WBC:
Protein RBC:
Sugars: EP.
Blood: Casts:
Crystals:
Stool –
ECG -
FINAL DIAGNOSIS:- Acute wall MI
DRUG WITH DOSE & ROUTE
DURATION OF THERAPY
GENERIC NAME BRAND NAME
1
2
3
4
5
6
7
8
9
8
8
√ √ √
√
√
√ √ √
√
√ √ √
√
√
DISCHARGE MEDICATIONS:
DISCHARGE MEDICATIONS:
Patient not discharged
DAY INVESTIGATIONS
D1
D2
D3
PR – beats/min
BP – mmHg
PR – 80 beats/min
BP – mmHg
PR – 86 beats/min
BP – 100/80 mmHg
REVIEW:
Visit after 1 week
DRUG TREATMENT CHART: PROGRESS CHART:
PPF
Medication Dose and
duration
1 2 3 4 5

27. PLANNING
❖ THERAPEUTIC MONITORING:
❖ TOXICITY MONITORING:
❖ DISCHARGE MONITORING:
❖ DISCHARGE MEDICATIONS:
ISOSEPTIC SHOCK-Riddhi
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28. POINT TO PATIENT
❖ About the disease:
❖ About lifestyle modifications:
❖ About medications:
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29. POINT TO physician
� ADJUST DOSING INTERVAL: Administration of a tetracycline with aluminum, calcium, or magnesium
salts significantly decreases tetracycline serum concentrations. The proposed mechanism is
chelation of tetracycline by the cation, forming an insoluble complex that is poorly absorbed from
the gastrointestinal tract. MANAGEMENT: The administration of tetracyclines and preparations
containing aluminum, magnesium, or calcium should be separated by two to four hours.
� MONITOR: Coadministration of a tetracycline may decrease theophylline plasma clearance and
increase theophylline levels. The mechanism is unknown. MANAGEMENT: If these drugs are given
concurrently, close clinical and laboratory monitoring of response and tolerance is
recommended.
ISOSEPTIC SHOCK-Riddhi
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30. POINT TO physician
� CONTRAINDICATED: Coadministration of ceftriaxone with calcium-containing solutions, even via
different infusion lines, may cause precipitation of ceftriaxone-calcium salt.
� MONITOR: Bowel cleansing as well as overuse of certain laxatives may cause electrolyte loss and
increase the risk of torsade de pointes ventricular arrhythmia in patients treated with drugs that
prolong the QT interval.
� MONITOR: Proton pump inhibitors may increase the rate of theophylline absorption from sustained-
release formulations. Chronic use of proton pump inhibitors produce sustained hypochlorhydria,
which may enhance peristalsis in the small intestine and antiperistalsis in the proximal colon where
theophylline is absorbed.MANAGEMENT: Patients should be advised to report any signs of
theophylline toxicity including nausea, vomiting, diarrhea, headache, restlessness, insomnia, or
irregular heartbeat to their physicians.
� MONITOR: The concomitant use of theophylline and corticosteroids may theoretically increase the
risk of hypokalemia due to additive potassium-lowering effects. MANAGEMENT: Monitoring for
altered efficacy and safety of theophylline and altered serum potassium and theophylline
concentrations is advisable when these drugs are coadministered.
� MONITOR: Chronic use of proton pump inhibitors (PPIs) may induce hypomagnesemia, and the risk
may be increased during concomitant use of diuretics or other agents that can cause magnesium
loss. Hypomagnesemia can also cause impaired parathyroid hormone secretion, which may lead to
hypocalcemia. MANAGEMENT: Monitoring of serum magnesium levels is recommended prior to
initiation of therapy and periodically thereafter if prolonged treatment with a proton pump inhibitor
is anticipated or when combined with other agents that can cause hypomagnesemia such as
diuretics
ISOSEPTIC SHOCK-Riddhi
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