CASE PRESENTATION ON GALL STONES

1. CASE PRESENTATION ON
CHOLELITHIASIS WITH GRADE 1 FATTY LIVER
KAVIYA AP
PHARM D
RA1522281010017

2. SUBJECTIVE EVIDENCE
• A female patient of age 33 years was admitted in the
general ward on Oct 21st 2018
• With the chief complaints of abdominal pain since 4
hours and nausea and vomiting for 1 week
• H/O Severe abdominal pain , bloating and indigestion
• No C/O Chest pain / palpitation

3. PAST MEDICAL HISTORY K/C/O Hypertension for 5 years
PAST MEDICATION
HISTORY
T.Inderal [ Propanolol ] 20mg
PERSONAL HISTORY Sleep pattern-normal
Loss of appetite
Loss of weight ( 7 kg reduced )
Disturbances in bowel and Bladder habit
Regular mensus
FAMILY HISTORY No relevant family history

4. GENERAL EXAMINATION O/E: Conscious, oriented.
TEMP: 98.7 F CVS : S1S2+
BP : 110/80 mm Hg CNS : NFND
PR : 72 b/min RS : B/L AE+
RR : 36 cycle/min P/A : Epigastric
tenderness
INVESTIGATIONS DONE Complete blood count
Liver function test
Renal function test
USG abdomen
Urine analysis
Sr Electrolytes

5. OBJECTIVE EVIDENCE
PARAMETERS OBSERVED RANGE NORMAL RANGE
Hb 10.7 11.5-16.5 g/dl
PCV 32 40-50%
TOTAL RBC COUNT 3.8 4.5-5.5 m/cumm
TOTAL WBC COUNT 7.1 4000-11000/cumm
NEUTROPHILS 68.4 40-80%
LYMPHOCYTES 27 20-40%
ESR 58 0-10 mm/hr
MCH 27 27-32 pg
MCV 32 83-101 fl
SODIUM 134 130-145 mmol/L
CHLORIDE 121 95-105 mmol/L

6. PARAMETERS OBSERVED VALUE NORMAL RANGE
TOTAL BILIRUBIN 1.7 0.5-1.0 mg/dl
DIRECT BILIRUBIN 0.5 upto 0.3 mg/dl
INDIRECT BILIRUBIN 1.3 0.2-0.7 mg/dl
TOTAL PROTEIN 6.7 6.0-8.0 g/dl
ALBUMIN 4.0 3.5-5.0 g/dl
GLOBULIN 2.7 2.5-3.0 g/dl
ALBUMIN/GLOBULIN RATIO 1.5 1.2-1.5
SGOT(AST) 411 5-40 U/L
SPOT(ALT) 383 5-35 U/L
ALKALINE PHOSPHATE 359 40-125 U/L
GAMMA GT 247 10-50 U/L

7. PARAMETERS OBSERVED VALUE NORMAL RANGE
LIPID PROFILE TEST
CHOLESTEROL 218 < 200 mg/dl
TRIGLYCERIDES 125 40-150 mg/dl
HDL 41 > 40 mg/dl
LDL 127 80-150 mg/dl
VLDL 25 <40 mg/dl
TOTAL CHOLESTEROL 5 3-5

8. DATE SPECIAL INVESTIGATIONS IMPRESSION
22.10.18 URINE ANALYSIS :
colour : yellow
appearance : clear
reaction : -
albumin : nil
epithelial cell : 1-2 cells
pus cells : Occasional
Normal
22.10.18 ULTRASOUND REPORT :
LIVER : Normal in size and shows
Increased echo texture.
GALL BLADDER : Mild GB wall edema
two calculi of 5mm are found
NOTE : Organised collection 34x26 mm seen in the
epigastric region below the stomach
Fatty liver
Cholelithiasis
22.10.18 MICROBIOLOGY REPORT :
Scanty growth of urethral commensal Infection

9. ASSESSMENT
FINAL DIAGNOSIS
Cholelithiasis
 Grade 1 - Fatty liver

10. THERAPEUTIC GOALS
To bring the normal function of the liver.
To monitor the electrolytes level in the body.
To avoid further complications of the liver.
To improve the quality of life of the patient.
PLAN

11. S.N DRUG NAME GENERIC NAME DOSE ROA FREQ DAYS
1 2 NS Normal saline I.V OD 1-9
2 Inj.Taxim CEFOTAXIME 1g I.V BD 1-9
3 Inj.Metro METRONIDAZOLE 500mg I.V BD 1-9
4 Inj.pan PANTOPRAZOLE 40mg I.V OD 1-9
5 Inj.Emeset ONDANSETRON 4mg oral BD 1-9
6 Inj.Tramadol TRAMADOL 100mg I.V 1-0-1 1-9
7 Inj.MVI VITAMIN SUPPLEMENT 10ml I.V 1-0-0 3-9
8 T.Udiliv URSODEOXYCHOLIC ACID 500mg oral OD 3-9
9 C.Astymine Forte AMINO ACIDS +
VITAMINS
oral OD 3-9

12. According to the standard guidelines,
There is no interactions found in the prescription.
DRUG INTERACTION

13. PHARMACIST INTERVENTION
• Since the Hb levels of the patient is low iron supplements can be prescribed.
• There is increased chloride level in blood , indicates patient is dehydrated. It
can also lead high Na content in blood and cause kidney problems so
continous monitoring of electrolytes and low Na diet is must.
• High cholesterol level is reported. Therefore use of statins is safer and can
improve liver test.

14. DISEASE COUNSELING
• Cholelithiasis is the formation of hardest deposit in the fluid
within the gall bladder.
• Decreasing the cholesterol content in the bile can easily dissolve
the gall stones.
• A high fiber , low fat diet helps to keep bile cholesterol level in
normal form.
• Rapid loss of weight can develop gall stones. Therefore get
counseling from dietician and improve normal weight.

15. DRUG COUNSELING
• T.Udiliv can cause discolouration of urine and black tarry stools. Do not
panic if these symptoms are seen.
• Take vitamin tablet in the morning, since they are synthetic substances
they are well absorbed when taken with food. Taking them at night can
interfere with sleep.
• Do not stop the course of antibiotics even if you are feeling better.if
treatment stops soon the remaining bacteria become resistant to the
antibiotic taken.

16. DIET COUNSELING
• Follow DASH diet.
• Weekly consume omega 3 fatty acid containing foods like salmon
and tuna fish ,as they reduce LDL level.
• Garlic is a staple in many diets, consumption of that is beneficial
for reduction of fatty liver disease.
• Potassium rich foods like banana , kiwi , milk and yogurt helps in
protecting liver from fatty deposits.
• Avoid foods and drinks that contain sugar especially fructose.
• Take carrot and beetroot juice in diet.

17. LIFESTYLE MODIFICATION
• Keep the body from dehydrating. Drink plenty of water.
• Clean the tube incised area with soap water gently and shower can
be taken regularly.
• Call healthcare provider when there is any yellowing of skin , belly
pain, rectal bleeding , swelling of legs and shortness of breath.
• Get enough sleep which is useful for build up of new RBC cells.
• Exercise regularly. Walk atleast 15 mins a day.
• Daily drink a glass of warm water with lemon and honey . It can
detoxify liver and helps it function normally.

18. Thank you