1. CASE PRESENTATION ON
GASTROENTERITIS AND ACUTE
RENAL FAILURE
BY P DEEPAK
5th year Pharm D

2. PATIENT DEMOGRAPHIC DETAILS
PATIENT NAME-XYZ
PATIENT AGE- 42YEARS
SEX-FEMALE
DATE OF ADMISSION- 11-06-2013

3. SOAP FOR GASTROENTERITIS

4. 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

5. OBJECTIVE EVIDENCE
Pathology report:
• Stools are semisolid in nature
• Mucus present greenish in colour
• Entamoeba histolytica cyst seen
• N: 83%(40-75%)
• L: 10%

6. 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:

7. Assessment of current therapy-
Tab Pantoprazole: 40 mg IV 1-0-1
Inj Ondansetron 4mg IV 1-1-1
Tab Sporolac 2-2-2
Cap Doxycycline 300mg stat
Inj Ciprofloxacin 100ml IV 1-0-1

8. TREATMENT CHART
DRUGS DOS
E
ROU
TE
FREQUE
NCY
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 100m
g
P.O 1-1-1 + + +
Cap
Doxycycline
300m
g
P.O stat + stop

9. 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

10. MONITORING PARAMETERS-
LABORATORY PARAMETERS-

11. SOAP FOR ACUTE RENAL FAILURE

12. SUBJECTIVE EVIDENCE
• C/o loose stools and vomiting

13. OBJECTIVE EVIDENCE
• Urea: 73mg %
• S. Cr: 3.2 mg%
• Cl: 114 mmol/lit
• K+: 3.2 mmol/lit
• Na+: 144 mol/lit
Urine 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

14. 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

15. Assessment of current therapy-
Tab Pantoprazole: 40 mg IV 1-0-1
Inj Ondansetron 4mg IV 1-1-1
Tab Sporolac 2-2-2
Cap Doxycycline 300mg stat
Inj Ciprofloxacin 100ml IV 1-0-1

16. TREATMENT CHART
DRUGS DOS
E
ROU
TE
FREQUE
NCY
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 100m
g
P.O 1-1-1 + + +
Cap
Doxycycline
300m
g
P.O stat + stop

17. 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

18. 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

19. • Food may be offered often in small amounts.
Suggested foods include:
• Cereals, bread, potatoes, meat
• Plain yogurt, bananas, fresh apples
• Vegetables