A case study on urinary tract infection , which gives a detailed study about UTI , the case study details about the treatment options , diagnosis , patient counselling , pharmacist interventions etc

1. A CASE STUDY ON URINARY
TRACT INFECTION
Submitted by
MARTIN SHAJI
Pharm D

2. PATIENT DEMOGRAPHY
Patient Name: Mr. X IP No: 31580
Admission date : 21.03.19. Discharge date: 24.03.19
Age: 48years Sex: M
Department: General Medicine

3. CHIEF COMPLAINTS:
Fever from 3 months on and off, abdominal pain during micturition.
HISTORY OF PRESENT ILLNESS:
Dysuria and myalgia since 3 months
No H/O bleeding, rashes, loose stools, vomiting
No H/O cough with expectoration
PAST MEDICAL HISTORY:
Nothing significant
ALLERGY :(food/drug/other)
No known allergies.

4. PERSONAL HISTORY AND HABITS:
Diet: Mixed.
Sleep: normal.
Appetite: normal.
Bowel and bladder: burning sensation and pain during micturition.
FAMILY HISTORY:
Nothing significant.

5. General Examination: Conscious and coherent
1. Physical examination:
Vital signs:
Temperature ( oF ): 101 Pulse rate (/min): 80beats
Respiratory Rate (/min): 25 cycles
Blood Pressure (mm of Hg): 150/80mm of Hg
2. Systems Examination:
• CVS: S1, S2 +
• RS: Clear
• GU &GI (ABDOMEN): Soft

6. 3. Laboratory Data:
1. Hb 14.00g (12-15g/dL)
2.WBC 12,100↑ (4,000-11,000cells/cu.mm)
3. DC:
N 75 40-70%
L 35 20-40%
E 4 1-6%
B 0 <1%
M 15 2-10%
4. RBS 115 80-120mg/dl

7. URINE ANALYSIS RESULT
Result Reference
standard/range
Color Yellow; hazy Yellow
Specific gravity (g/ml) 1.018 1.005_1.030
Blood Trace Negative
Ketone Negative Negative
Glucose Negative Negative
Bacteria 3+ Non
WBC 40-100/hpf 0-5/hpf

8. URINE CULTURE TEST
Isolated
bacteria
Number
of sample
Frequency
ESCHERICHIA
COLI
58 81.69

9. SOAP NOTES
SUBJECTIVE EVALUATION:
A 50 years old male patient was admitted with the complaints of
fever from 3 months on and off, abdominal pain during
micturition. Dysuria and myalgia was present since 3 months.
Burning sensation and pain during micturition was present.
OBJECTIVE EVALUATION:
On Examination, the patient was conscious & coherent. BP
levels were elevated - 150/80 mmHg
Lab data reveals slight elevation in WBC- 12,100cells/cu.mm
ASSESSMENT:
Based on subjective & objective evaluation the
physician confirmed it as URINARY TRACT INFECTION.

10. DRUG CHART
Sl.No. Drug -
Indication Dose ROA
Frequ-
ency
Start &End
date
Brand Name Generic Name
1. T.
NORFLOXACIN
T. NORFLOXACIN Antibacterial
(fluoroqquinolones
)
500 mg P/O BD
21/3/19to
24/3/19
2. INJ. PARA INJ.. Paracetamol Antipyretic &
analgesic 150mg IV BD
21/3/19to
24/3/19
3. INJ. RANTAC INJ. Ranitidine H-2 blocker
25mg
IV BD
21/3/19to
24/3/19
4. T. BCT T. B Complex Vitamin
supplement 63mg
P/O OD
21/3/19to
24/3/19
5. INJ.
TRAMADOL
INJ. TRAMADOL Opioid analgesic
50mg IV BD
21/3/19to
24/3/19

11. PLANNING
On Day-I:
• Tab. Norfloxacin 500mg P/O BID is used as an Antibiotic. Which may
reduce microbial action .
• Inj. Ranitidine 25mg IV BD is used as an anti-ulcerative drug. Reduce
stomach irritation ,do not take more than two weeks.
• Inj. Paracetamol 150mg IV BID is used as an anti-pyretic. It act as a pain
killer and also as temp lower.
• Inj. Tramadol 50mg IV BID is an opioid analgesic given to reduce the
pain. Use twice daily.
Tab. B-complex 63mg P/O OD used as a vitamin supplement. Use one
tablet in morning and night.

12. PLANNING…
• On Day-2 & On Day-3:
Continue same medication.
• On Day-4:
On fourth day patient was continued with the same medication because of no fresh
complaints.
As the patient was symptomatically better, he was discharged with the following
medications and asked to review after 1 week.
Rx,
1. T.Norfloxacin 500mg BID
2. T. Ranitidine 150 mg BID
3. T. Paracetamol 500 mg TID
4. T. Tramadol 100mg BID
5. T. B-complex 63mg OD

13. PHARMACIST INTERVENTIONS
1. The BP level was elevated but neither treatment nor
further BP checkup was done.
2. No DDI or ADRs were found.

14. • You should wipe from front to back after urinating or a bowel
movement. You should drink plenty of fluids. Drinking cranberry juice
may be helpful. Women prone to UTIs should avoid using birth
control methods such as a contraceptive diaphragm and spermicidal
jelly.

15. There are several ways you can prevent UTIs. You should keep
your genital area clean and wear clean, dry cotton
underwear. You should wipe from front to back after
urinating or a bowel movement. You should drink plenty of
fluids. Drinking cranberry juice may be helpful.
Women prone to UTIs should avoid using birth control
methods such as a contraceptive diaphragm and spermicidal
jelly. Women should not douche or using similar feminine
hygiene products. Women and girls should avoid bubble bath
products. Bubble baths do not cause a UTI, but they can
irritate the urinary tract.
You should urinate after sexual intercourse. Some women
consistently develop UTIs after sexual intercourse. In these
cases, doctors can prescribe an antibiotic that is taken after
sexual intercourse as a preventive measure.

16. REGARDING LIFE STYLE MODIFICATIONS:
•Patient is advised to maintain proper hygiene.
•Advised to drink plenty of water.
•Citrus juices should be taken.
•Limit caffeine intake
•Avoid OTC preparations.
•The patient given appropriate advice regarding
transmission and re infection.

17. THANK
YOU.