clinical pharmacy case study

1. Case 4: ACUTE
PYELONEPHRITIS
Melba Ann Cara T. Macasaet II
MWF 11:00-12:00pm

2. General Patient Information
Feb 2, 2010
Patient: Rab
Age: 21 yo
Gender: Female

3. Chief Complaint
• Dysuria
• Fever

4. History of Present Illness
Feb 15, 2010
• Fever – temporarily relieved with paracetamol
• Complaining of dysuria and urinary frequency and urgency
Feb 16, 2010
• Still has fever
• Vomiting
• Backpain
• Epigastric abdominal pain
• Decrease appetite
• Complain promt admission

5. Social History
Smoke: Occasionally
Alcohol: Drinks Occasionally
Illicit Drug Use: Not Mentioned
Occupation: Not Mentioned
Marital Status: Not Mentioned

6. Family History
Not Mentioned

7. Medication History
Drug Feb 18 2010 Feb 19 2010 Feb 20 2010
Paracetamol 500mg q4h prn prn
Cefuroxime(zinacef) 750mg ivtt q8h 750mg ivtt q4h Shift to zinnat 500mg PO
BID
Ranitidine ( Zantac) 50mg ivtt q8h 50mg ivtt q8h D/C
Lactulose (Duphalac) 15ml PO @ bedtime 15ml PO @ bedtime D/C
Betahistine (Serc) 8mg PO TID 8mg PO TID D/C
Sabutamol+ipratropium
(Combivent)
1 neb q8h 1 neb q8h D/C
Bisacodyl (Dulcolax) 10mg sup OD @ bedtime D/C supp, 5mg tab OD
9PM
5mg tab OD 9PM
D5 NSS iL @ 40 gtts iL @ 40 gtts iL @ 40 gtts

8. Review of System
Acute Pyelonephritis

9. Physical Examination
BP 120/80 mmHg
HR 86 bpm
RR 17bpm
Oral Temperature 38.6°C
Weight 60kg

10. Laboratory and Diagnostic Test Results
feb 18 2010
Urinalysis: WBC ++
slightly cloudy appearance
Ultrasound: normal
Urine Culture: no bacterial growth after 2days incubation
Test Result Normal Range
WBC 11.39 4.1-10.9 x 10 °/L
Neutrophils 86 47-80%
Lymphocytes 8 13-40%

11. Problem list and Initial plan
Problem 1: DYSURIA – given cefuroxime (zinacef)
Problem 2: FEVER – paracetamol 500mg

12. S O A P
Dysuria
Fever
Vomiting
Back pain
Epigastric abdominal pain
Decrease appetite
Patient 21 yo
Female
BP 120/80 mmHg
HR 86 bpm
RR 17 bpm
Oral temp. 38.6°C
Weight 60 kg
Acute pyelonephritis Feb 18 2010
paracetamol (biogesic) 500mg
q4h,Cefuroxime (zinacef) ivtt
q8h, ranitidine (zantac) 50mg
ivtt q8h, lactulose (duphalac)
15ml PO @bedtime,
Betahistine (serc)8mg TID,
Sabutamol+ipratropium
(Combivent) 1 neb q8h,
Bisacodyl (Dulcolax) 10mg
supp OD @ bedtime, D5 NSS
iL 40 gtts
Feb 19 2010
Paracetamol (biogesic) 500mg
PRN, Cefuroxime (zinacef) ivtt
q8h, ranitidine (zantac) 50mg
ivtt q8h, lactulose (duphalac)
15ml PO @bedtime,
Betahistine (serc)8mg TID,
Sabutamol+ipratropium
(Combivent) 1 neb q8h,
Bisacodyl (Dulcolax) D/C supp,
5mg tab OD 9PM, D5 NSS iL 40
gtts

13. S O A P
Feb 20 2010
Paracetamol (biogesic) 500mg
PRN, Cefuroxime (zinnat)
500mg PO BID, Ranitidine (
Zantac) D/C, Lactulose
(Duphalac) D/C, Betahistine
(Serc) D/C,
Sabutamol+ipratropium
(Combivent) D/C, Bisacodyl
(Dulcolax) D/C, D5 NSS iL 40
gtts
Non-drug therapy
quit smoking
quit alcohol drinking
increase water intake
diet