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CASE PRESENTATION ON
ACUTE GASTERO ENTERITIS
K.SAI GOWTHAM
ІІ PHARM D
17P91T0009
DETAILS OF THE PATIENT :
A 45 year old female patient bearing I.P.NO:15632
was admitted in General ward on 21/12/18 and got
discharged on 25/12/18. The length of stay of
patient in the hospital was 5 days .
CHIEF COMPLAINTS:
 Loose stools
 Vomiting
 Abdominal pain
 Patient was conscious and Afebrile.
PAST MEDICAL HISTORY:
Hyperthyroidism.
SOCIAL HISTORY:
 Married
 Non - vegetarian
The physical exam on admission revealed the following findings:
 TEMP : 98.6 F
 PULSE : 82/min
 RR : 22/min
 BP :140/90mm Hg
 CVS : S1S2 +,
Vitals chart
VITALS DAY 1 DAY 2 DAY 3 DAY 4 DAY 5
BP (mm
of Hg)
140/90 150/90 130/90 120/90 100/80
RESP
(breathe
/min)
22 22 24 24 24
PULSE(b
pm)
82 86 90 92 80
TEMP 98.6 98.6 98.6 98.6 98.6
Laboratory investigations:
PARAMETERS RESULTS NORMAL RANGE
Haemoglobin 10.4 14 – 16 mg/dl
ESR 12 Upto 20mm/hr
PCV(packed cell volume) 31.8 38 – 47%
Total WBC 3100 4500 – 11000 cells/mm3
Eosinophils 6 2 – 6%
Total RBC 4 .3 4.3 – 5.5 mm3
Other tests:
Gastroscopy
 Normal gastrointestinal tract Affected gastrointestinal tract
DIAGNOSIS:
Acute Gastroenteritis
Causes of gastroenteritis:
1.Salmonella spp.
2.Enteropathogenic E.coli
3.Vibiro spp.
Treatment:
TRADE NAME GENERIC
NAME
DOSE ROA FREQUENC
Y
Treatment
1 2 3 4 5
INJ Emeset ondansetron 8mg/m
l
IV BD
INJ Metrogyl Metronidazol
e
500mg
/100ml
IV TID
CAP Pantacid pantoprazole
40mg
PO OD
INJ Monocef Ceftriaxone 1g/ml IV BD
T Neo
mercazole
Carbimazole 20mg PO TID
T Indreal Propranolol 40mg PO TID
+ + + + +
+ + + + -
+ + + + -
+ + + + +
+ + + + -
+ + + + +
SOAP NOTES
SUBJECTIVE:
 Loose stools
 Abdominal pain
 vomiting
OBJECTIVE:
 Decreased pcv
 Decreased haemoglobin
 Decreased WBC
Assessment:
DRUG INTERACTIONS:
No known drug interactions were found.
 Consumption of alcoholic beverages during treatment with
metronidazole is not recommended.
 It may occasionally trigger reaction in some patient similar
to disulfiram reaction.
 Metanidazole and ceftriaxone may interact with certain
foods and disease.
Plan
 To treat the dehydration caused
by loose stools. electrolyte
replenishers are suggested.
 Ondansetron, metronidazole and
pantoprazole are recommended
to treat acute gastroenteritis.
 Carbimazole is recommended to
treat hyperthyroidism.
 Propranolol is recommended to
treat increased blood pressure.
 Iron supplement is suggested to
improve haemoglobin level.
 Vitamin c supplements' are
suggested to increase WBC levels
in body.
Patient education:
Patient is adviced to take the medication regularly,
 Patient is adviced to report any signs of adverse effects,
 Proper diet should be taken with plenty of water or electrolyte
replenisher or rehydration liquid may be helpful.
 Regular check up of thyroid levels.
Life style modifications:
 Advised the patient to avoid tea, coffee and soda which may
worsen the condition.
 Try to minimise stress and to induce food like banana, apple, rice
which will help to treat the diarrhoea, associated gastroenteritis.
 Practice good hygienic conditions.
 Prefer regular exercise.
Acute gastroenteritis case presentation
Acute gastroenteritis case presentation
Acute gastroenteritis case presentation

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Acute gastroenteritis case presentation

  • 1. CASE PRESENTATION ON ACUTE GASTERO ENTERITIS K.SAI GOWTHAM ІІ PHARM D 17P91T0009
  • 2. DETAILS OF THE PATIENT : A 45 year old female patient bearing I.P.NO:15632 was admitted in General ward on 21/12/18 and got discharged on 25/12/18. The length of stay of patient in the hospital was 5 days .
  • 3. CHIEF COMPLAINTS:  Loose stools  Vomiting  Abdominal pain  Patient was conscious and Afebrile.
  • 4. PAST MEDICAL HISTORY: Hyperthyroidism. SOCIAL HISTORY:  Married  Non - vegetarian
  • 5. The physical exam on admission revealed the following findings:  TEMP : 98.6 F  PULSE : 82/min  RR : 22/min  BP :140/90mm Hg  CVS : S1S2 +,
  • 6. Vitals chart VITALS DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 BP (mm of Hg) 140/90 150/90 130/90 120/90 100/80 RESP (breathe /min) 22 22 24 24 24 PULSE(b pm) 82 86 90 92 80 TEMP 98.6 98.6 98.6 98.6 98.6
  • 7. Laboratory investigations: PARAMETERS RESULTS NORMAL RANGE Haemoglobin 10.4 14 – 16 mg/dl ESR 12 Upto 20mm/hr PCV(packed cell volume) 31.8 38 – 47% Total WBC 3100 4500 – 11000 cells/mm3 Eosinophils 6 2 – 6% Total RBC 4 .3 4.3 – 5.5 mm3
  • 9.  Normal gastrointestinal tract Affected gastrointestinal tract
  • 10. DIAGNOSIS: Acute Gastroenteritis Causes of gastroenteritis: 1.Salmonella spp. 2.Enteropathogenic E.coli 3.Vibiro spp.
  • 11. Treatment: TRADE NAME GENERIC NAME DOSE ROA FREQUENC Y Treatment 1 2 3 4 5 INJ Emeset ondansetron 8mg/m l IV BD INJ Metrogyl Metronidazol e 500mg /100ml IV TID CAP Pantacid pantoprazole 40mg PO OD INJ Monocef Ceftriaxone 1g/ml IV BD T Neo mercazole Carbimazole 20mg PO TID T Indreal Propranolol 40mg PO TID + + + + + + + + + - + + + + - + + + + + + + + + - + + + + +
  • 13. SUBJECTIVE:  Loose stools  Abdominal pain  vomiting
  • 14. OBJECTIVE:  Decreased pcv  Decreased haemoglobin  Decreased WBC
  • 15. Assessment: DRUG INTERACTIONS: No known drug interactions were found.  Consumption of alcoholic beverages during treatment with metronidazole is not recommended.  It may occasionally trigger reaction in some patient similar to disulfiram reaction.  Metanidazole and ceftriaxone may interact with certain foods and disease.
  • 16. Plan  To treat the dehydration caused by loose stools. electrolyte replenishers are suggested.  Ondansetron, metronidazole and pantoprazole are recommended to treat acute gastroenteritis.  Carbimazole is recommended to treat hyperthyroidism.  Propranolol is recommended to treat increased blood pressure.  Iron supplement is suggested to improve haemoglobin level.  Vitamin c supplements' are suggested to increase WBC levels in body.
  • 17.
  • 18. Patient education: Patient is adviced to take the medication regularly,  Patient is adviced to report any signs of adverse effects,  Proper diet should be taken with plenty of water or electrolyte replenisher or rehydration liquid may be helpful.  Regular check up of thyroid levels. Life style modifications:  Advised the patient to avoid tea, coffee and soda which may worsen the condition.  Try to minimise stress and to induce food like banana, apple, rice which will help to treat the diarrhoea, associated gastroenteritis.  Practice good hygienic conditions.  Prefer regular exercise.