The document provides details of a patient's hospital admission and treatment. It includes demographic information, chief complaints, medical history, examination findings, assessments, and treatment plans over 8 days. The 59-year-old female presented with accidental burns on both feet and lower back pain. She was diagnosed with burns, UTI, sepsis, and acute kidney injury. Her treatment included IV antibiotics, analgesics, diuretics, and anticoagulants. Her condition gradually improved over the course of her hospital stay.

1. Done by A.J.Vishali

2. PATIENT DEMOGRAPHIC DETAILS:
PATIENT NAME: Mary margarat
AGE:59yrs
SEX: female
IP NO. : 1701015
DOA: 25-8-18
DOD:5-9-18(death)
WEIGHT:55kgs
HEIGHT:154cms
BMI:23.2kg/m2
LBW:46.9kgs
BSA:1.53m2
DEPARTMENT:GENERAL MEDICINE

3. SOAP ANALYSIS
 S-SUBJECTIVE
 O-OBJECTIVE
 A-ASSESSMENT
 P-PLANING

4. S-SUBJECTIVE EVIDENCE
CHIEF COMPLAINTS: burn both foot until ankle and
lower backache
PAST MEDICAL HISTORY: handicapped since birth,
RT upper & lower limb deformity with difficulty
walking
PAST MEDICATION HISTORY: nil
SOCIAL HISTORY: nil
PRELIMINARY DIAGNOSIS: BURN DM
FINAL DIAGNOSIS: Accidental burns ,UTI with sepsis
with renal impairement

5. O-OBJECTIVE EVIDENCE
VITAL PARAMETERS:
PR-82/min
Bp-130/80mmhg
Oedema of feet: yes
RFT:
Blood urea:52mg/dl
Serum creatinine: 1.9
Bp: 130/80mmhg
TLC-19600

6. A-ASSESSMENT
From the subjective and objective evidence the patient is
suffering from accidental burns, UTI, sepsis, AKI.

7. BURNS:
DEFINITION:
The term “burn” means more than the burning
sensation associated with this injury. Burns are
characterized by severe skin damage that causes the
affected skin cells to die.

9. Pathophysiology
 At temperatures greater than 44 °C (111 °F), proteins begin losing
their three-dimensional shape and start breaking down . This
results in cell and tissue damage. Many of the direct health effects
of a burn are secondary to disruption in the normal functioning of
the skin. They include disruption of the skin's sensation, ability to
prevent water loss through evaporation, and ability to control
body temperature. Disruption of cell membranes causes cells to
lose potassium to the spaces outside the cell and to take up water
and sodium.
 In large burns (over 30% of the total body surface area), there is a
significant inflammatory response. This results in increased
leakage of fluid from the capillaries, and subsequent tissue edema.
This causes overall blood volume loss, with the remaining blood
suffering significant plasma loss, making the blood more
concentrated. Poor blood flow to organs such as the kidneys and
gastrointestinal tract may result in renal failure and stomach
ulcers.
 Increased levels of catecholamines and cortisol can cause a
hypermetabolic state that can last for years. This is associated with
increased cardiac output, metabolism, a fast heart rate, and poor
immune function.

12. PLANING:
DAY 1
Every day follow up:
25-8-18
RFT:
Blood urea:52mg/dl
Serum creatinine: 1.9
Bp: 130/80mmhg
TLC-19600

13. DAILY FOLLOWUP:
25-8-18:accidental burns both legs untill ankel
4 am-
Rx-
1.Ivf ns and rl -50ml
2.Inj cegava -1.14g-IV-BD
3.Inj pantop -40mg-IV-BD
4.Inj tramadol 1amp IV BD
5.Inj optineuron IM OD
6.Check GRBS

14. DI:
MINOR:
OPTINEURON<>PANTOP- supressing GI secretion, interferes GI absorption of optineuron
11am:
H/o- pain both knee joints, swelling of feet, nausea,
constipation- pedal edema. ?ckd. So avoid nsaids ,
aminoglycosides , ACEI , ARBI
Rx-
Inj metrogyl 100ml IV tid
Inj cegava 1.05g IV BD
Inj pan 40mg IV BD
Inj tramadol 1amp IM BD
Inj optineuron 1amp IV OD
DI: minor:
metrogyl<>tramadol- rarely prolongs QT interval

15. MECHANISM OF ACTION:
1.Inj cegava
MOA:Cegava 1000 mg/500 mg Injection is a combination of
two medicines: Cefoperazone and Sulbactam. Cefoperazone
is an antibiotic. It works by preventing the formation of the
bacterial protective covering which is essential for the
survival of bacteria. Sulbactam is a beta-lactamase inhibitor
which reduces resistance and enhances the activity of
Cefoperazone against bacteria.
ADRS:
 Diarrhea
 Altered liver function test
 Allergic reaction

16. 2.Inj pantop
MOA:Pantop 40 Tablet is a proton pump inhibitor (PPI). It works by
reducing the amount of acid in the stomach which helps in relief
of acid related indigestion and heartburn
ADRS:
 Vomiting
 Headache
 Stomach pain
 Nausea
3.Inj tramadol
MOA:Tramadol Hydrochloride 50 mg Injection is an opioid
analgesic (pain reliever) which works by blocking transmission of
pain signals to the brain to lower pain perception.
ADRS:
 Dizziness
 Sleepiness
 Vomiting

17. 4.Inj optineuron:
MOA: Pyridoxine, A Vitamin B6 Supplement Is Required For The
Proper Function Of Glucose, Fats, And Proteins In The Body. It Is
Also Required For The Growth And Development Of The Brain,
Nerves, Skin, And Many Other Parts Of The Body.
ADRS: Long Term Administration Of Large Doses Is Associated
With The Development Of Severe Peripheral Neuritis Resulting In
Numbness And Pain, Usually In Hands And Feet.
5.Inj metrogyl
MOA: Metrogyl 400 Tablet is an antibiotic. It kills the bacteria and
other microorganisms that cause infections by damaging their
DNA.
ADRS:
Headache
Dryness in mouth
Nausea

18. DAY 2:
26-8-18: type 2 DM/ burns
9am
Rx-
CST+ tab zymoflam

19. 6.Tab zymoflam
MOA:Bromelain Is A Mixture Of Enzymes That Digest Protein
(proteolytic) That Are Found In Pineapples (Ananas
Comosus).
Trypsin Breaks Down Proteins Into Smaller Fragments Thereby
Making It Available For Absorption Into The Blood Stream.
Trypsin When Applied Directly To Wounds And Ulcers
Removes Dead Tissue And Improves Healing.
Rutoside Trihydrate Is Known To Interact With Other Drugs
Like Amiloride (HCl), Ascorbic Acid, Ciprofloxacin,
Docetaxel, Gemifloxacin, Hydrochlorothiazide,
Lomefloxacin (HCl), Spironolactone, Triamterene. Always
Consult Your Physician For The Change Of Dose Regimen Or
An Alternative Drug Of Choice That May Strictly Be
Required.
ADRS:Nausea, Stomach Upset, Skin Rash, Acute Toxicity

20. DAY 3
11 am:
27-8-18
LFT:WNL
PT WITH INR: 12.36 sec , 1.0
APTT: 34.19sec
Bp: 110/80mmhg, PR:82/min
CBP:
Hb: 10.2%
WBC: 15000
Platelet count: 2.84 L
SERUM ELECTROLYTES:
Sodium: 127
Potassium: 4.0
Chloride:106

21. 27-8-18:
9am
Accidental burns,UTI with sepsis with renal impairment
CAD-MOD LV DYSFUNCTION
C/O-SWEATING
Rx-
CST
+
Inj fragnim 5000 OD
Tab atchol 40mg
High salt diet
Advice all lab tests

22. 7.Inj fragnim:
MOA:Fragmin 5000 IU Solution for Injection is an anticoagulant
that prevents the formation of harmful blood clots.
ADRS:
 Bleeding
 Injection site reaction
8.Tab atchol
MOA:Atchol 40 Tablet is a lipid-lowering medication (statin). It
works by blocking an enzyme (HMG-CoA-reductase) that is
required in the body to make cholesterol. It thus lowers "bad"
cholesterol (LDL), triglycerides and raises "good" cholesterol
(HDL).
ADRS:
 Headache
 Stomach pain
 Constipation
 Feeling sick

23. 11am
Rx-
Cst+Tab ecoprine, k bind sachet
DI:
moderate:
Ecosprine <> zymoflam- increase GI ulcer and bleeding
Major:
Ecosprin<>fragnim- increase the risk of bleeding
Zymoflam<>fragnim- increase in bleeding complications
9.Tab ecosprine:
MOA: Ecosprin 75 Tablet is a non-steroidal anti-inflammatory drug (NSAID) with
anti-platelet action. It works by preventing platelets from sticking together
which decreases the formation of harmful blood clots. This lowers the chance
of heart attack or stroke.
ADRS:
 Gastritis
 Bleeding disorder
 Low blood platelets
 Gastric erosion
 Gastric ulcer

24. DAY 4
28-8-18:
Sodium: 127
Bp: 100/60mmhg, PR:74/min
Sodium: 128
Potassium:4.6
Creatinine:1.6
Urea:52
Accidental burns both legs untill ankel, DM,UTI with
sepsis,HYPONATREMIA(Na+ 127) , LV clot+, EF- 45%,stroke
,antery thrombosis
CST
+
Tab acitron
Removed ecosprin , k bind, high salt diet

25. 10.Tab acitron:
MOA:Acenocoumarol/Nicoumalone is an oral
anticoagulant. It acts by preventing the formation of
harmful blood clots. Although it does not dissolve the
existing blood clots, it inhibits them from growing
larger and causing serious problems.
ADRS:Bleeding

26. DAY 5
29-8-18: CAD with apical stent – on anticoagulant , DM, accidental burns ,
uti,sepsis
c/o – pedal edema , decrease pyramidal movements
CST
+
Tab dytor 10mg OD
Tab ecosprin 75mg OD
Inj pyeropenum 1g IV BD
DI:
Moderate:
1. dytor<>cegava –dose adjustment needed
2. Metrogyl<>dytor-increase blood levels of dytor
3. Dytor<>pantop-sometimes causes hypomagnesemia

27. 11.Tab dytor
MOA: Torasemide is a diuretic. It removes extra water and
certain electrolytes from the body by increasing the amount
of urine produced. In doing so, it causes potassium loss.
ADRS: Dizziness, Weakness, Dehydration, Decreased
potassium level in blood, Increased blood uric acid,
Decreased magnesium level in blood, Increased thirst
12.Inj pyeropenum
MOA:Meropenem exerts its bactericidal activity by
inhibiting bacterial cell wall synthesis in Gram-positive
and Gram-negative bacteria through binding to multiple
penicillin-binding proteins (PBPs).
ADRS:nausea, vomiting

28. DAY 6
30-8-18: GC-FAIR
Sodium:136
Potassium: 2.3(dytor drug cause low potassium
levels)
Chloride: 105
Serum creatinine: 0.9
WBC: 18900cells/cumm
Bp:100/70mmhg,PR:78/min

29. 30-8-18: accidental burns /UTI/SEPSIS/ AKI recovering with
DM with severe hypokalemia (k+= 2.3) ADR,LV apical
clot+
9am
CST
+
Inj kcl -2amp in 30ml ns IV
Syp potklor 15 ml tid
ADVICE INR AND PT LEVELS
DI:
Minor: kcl<>optineuron: decrease GI absorption of optineuron
12.Inj kcl
MOA:Kcl Injection works by raising potassium levels in
your blood.
ADRS:injection site reactions (pain, swelling, redness)

30. 4pm
PT-36.24,INR-5.8
CST + inj augmentin 1.2g IV tid
Withhold tab acitron 2mg OD
13.Inj augmentin:
MOA:Augmentin 1.2gm Injection is a combination of two
medicines: Amoxycillin and Clavulanic Acid. Amoxycillin is
an antibiotic. It works by preventing the formation of the
bacterial protective covering which is essential for the
survival of bacteria. Clavulanic Acid is a beta-lactamase
inhibitor which reduces resistance and enhances the activity
of Amoxycillin against bacteria.
ADRS:
 Vomiting
 Nausea
 Diarrhea

31. DAY 7: GC-POOR
Bp: 110/70mmhg,PR:78/min
31-8-18: Accidental burns/ UTI /SEPSIS/ DM with severe
hypokalemia correction
Increase intake of coconut water and bananas.
CAD with LV Clot with mod dysfunction
CST
+
Tab atorvas
Tab dolo650
Inj biopipe t2
Mgso3 -1amp
Stop cegava
DI:
moderate:
mgso4<>dytor- risk of dehyration and electrolyte abnormalities.
Atorvas<>pantop-increase blood levels of atorvas
Metrogyl<>atorvas-increase of nerve demage

32. 14.Tab atorvas
MOA:Atorva 20 Tablet is a lipid-lowering medication (statin).
It works by blocking an enzyme (HMG-CoA-reductase) that
is required in the body to make cholesterol. It thus lowers
"bad" cholesterol (LDL), triglycerides and raises "good"
cholesterol (HDL).
ADRS:
 Headache
 Stomach pain
 Constipation
15.Tab dolo
MOA:Dolo 650 mg Tablet is an analgesic (pain reliever) and
anti-pyretic (fever reducer). It works by blocking the release
of certain chemical messengers that cause pain and fever.
ADRS:No common side effects seen

33.  Pt is on kcl transfusion
Inj piptaz
Inj linezolid
DUPLICATIONS:
Cegava,metrogyl,augmentin- beta lactam antibiotics and
inhibitors
Ecosprine, zymoflam- NSAIDS

34. 16.Inj piptaz
MOA: Piptaz 4.5gm Injection is a combination of two medicines:
Piperacillin and Tazobactum. Piperacillin is an antibiotic. It works
by preventing the formation of the bacterial protective covering
which is essential for the survival of bacteria. Tazobactum is a
beta-lactamase inhibitor which reduces resistance and enhances
the activity of Piperacillin against bacteria.
ADRS:
 Allergic reaction
 Nausea
 Diarrhea
17.Inj linezolid
MOA:Lnz 600 Infusion is an antibiotic. It stops bacterial
growth by preventing synthesis of essential proteins required
by bacteria to carry out vital functions
ADRS:
 Nausea
 Decreased blood cell count
 Diarrhea

35. DAY 8:GC-FAIR
1-9-18:
TLC: 25000cells/cumm
GRBS:258mg/dl
INR: 1.61
Bp: 130/80mmhg,PR:78/min
1-9-18: c/o- ADR(mgso3, ecosprine)caused bleeding pv –clot
noted with lower abd pain (supra pubic region) , mod LV
dysfunction with apical clot , accidental burns , sepsis ,UTI,AKI
improved
Inj vitk IM stat
Inj tramadol IM stat
Tab ecosprin
Kcl
Tab acetrone
Inj frag
Inj optineuron

36. :
Inj piptaz -4.5g IV tid
Inj linezolid- 600mg IV bd
Tab dolo -650mg oral tid
Inj fragnim -5000u s.c od
Ivf with optineuron 1amp in 1 ns IV
Tab zymoflam tid
Inj pan 40mg IV od
Tab atorvas od
GRBS
DI:
Major: zymoflam<>fragnim- increase risk of bleeding
Moderate:atorvas<>pan-increase bloodlevels & effects of
atorvas
Atorvas<>linezolid-increase risk of bleeding

37. DAY 9
 2-9-18:
Bp: 90/60mmhg
Spo2:98%
PR:106/min

38.  2-9-18: CAD with mod LV dysfunction with apical clot with
DM with accidental burn with UTI with sepsis
Rx
CST
+
Inj H.mixtard
Inj HAI
Inj fragnim 5000u OD
Syp ancool 2amp tid
Inj tramadol 1amp IV
ns@ 3000hr with 1amp optineuron
Inj calcium
Inj nahco3 100ml
DI:
Major: tramadol<>linezolid: increase risk of serotonin
syndrome

39. Moderate: ancool<>tramado-prolong qt interval
HAI<> linezolid: increase risk of hypoglycemia
18.Syp ancool
MOA:Ancool Oral Suspension Sugar Free is a combination of
four medicines: Aluminium hydroxide, milk of magnesia,
simethicone and oxetacaine. Aluminium hydroxide is an
inorganic salt that neutralises the excess acid in stomach.
Milk of magnesia is a laxative that works by drawing water
into the intestine through osmosis, making the stools soft
and easier to pass. Simethicone is an antifoaming medicine
which disintegrates gas bubbles and allows easy passage of
gas. Oxetacaine is a local anesthetic that provides faster relief
from pain due to ulcers or acidic injury in the stomach.
ADRS:
 Diarrhea
 Constipation
 Allergic reaction

40. 19.Inj ca gluconate
MOA: Calcium Gluconate provides essential nutrients.
ADRS: Central nervous system depression, Coma, Ectopic
mineralization
20.NAHCO3
MOA: Sodium Bicarbonate is an antacid and alkalizer. It works
by neutralizing excess acid in stomach.
ADRS: Constipation, Muscle twitching, Irritability
Ancool<>tramadol- cause bardycardia

41. DAY10
3-9-18:
GRBS: 240mg/dl
Spo2: 91%
3-9-18: DM,Mod lv dysfunction, lv clot, decubitus ulcer, accidental
burns ,UTI, s/p- CPR (hypotension) developed sudden episodes of
bradycardia-cardiac arrest
9am
Inj linezolid 600mg iv tid
Inj piptaz 4.5g iv tid
Inj pan 40mg iv od
Inj fragnim 5000u sc od
Inj optineuron 1amp iv od
Tab zymoflam tid
Tab dolo 650mg tid
Tab atorvas 80mg od
Syp ascoril

42. 20.Syp ascoril
MOA: Ascoril C Syrup is a combination of two
medicines: Chlorpheniramine Maleate and Codeine,
which relieves dry cough. Chlorpheniramine Maleate
is an antiallergic. It blocks the action of a chemical
messenger (histamine) which may trigger cough due
to allergy. Codeine is a cough suppressant. It
suppresses cough by reducing the activity of cough
center in the brain.
ADRS: Nausea,Vomiting,Constipation

43. 11 am: post CPR status respiratory failure on mechanical
ventillation, aspiration pneumonia (ascoril <> linezolid)
Shock-septic, cardiac
Patient may deteriorate further , possibility of cardiac arrest and
death explained, grave prognosis
Inj colistin
Inj tegicycle
Inj dalaci 600 iv tid
Inj pan 40mg iv tid
Inj ondem 4mg iv tid
Inj imyen
Inj fragnim
Tab atchol
Inj hydrocestin
Inj optineuron
Start ABG@9.8m start adrenaline@1.4mg/hr

44. 21.Inj colistin
MOA: Colistin 1 MIU Injection is an antibiotic. It kills bacteria
by destroying the bacterial cell membrane.
ADRS:
 Injection site reactions (pain, swelling, redness)
 Neurotoxicity
 Kidney damage
22.Inj tegicycle
MOA: Tigi 50 mg Injection is an antibiotic. It stops bacterial
growth by preventing synthesis of essential proteins required
by bacteria to carry out vital functions.
ADRS:
 Headache
 Vomiting
 Nausea

45. 23.Inj dalacin
MOA: Dalacin C 600 mg Injection is an antibiotic. It works by
preventing synthesis of essential proteins required by
bacteria to carry out vital functions. Thus, it stops the
bacteria from growing, and prevents the infection from
spreading.
ADRS:
 Vomiting
 Stomach pain
 Nausea
 Diarrhea

46. DAY 11
4-9-18:
GRBS:179mg/dl
Hb: 8.1
Platelet: 4.79
TLC:31800
RFT:
Urea: 70
Creatinine: 1.6
HR: 140/min,bp:110/60mmhg

47. 4-9-18: 11am:
mod lv dysfunction,apical clot, accidental burns, uti, aspiration
pneumonia, sepsis- septic.cardiac,AKI with encephalopathy
Rx-CST
Shock on noradrenaline,dobutamin,vasopressin,adrenaline
2pm:
CST+
Inj ceftrazidine 2g iv bd
Inj imyen
Inj HAI
Inj optineuron
Tab ivabrad 5mg bd

48. DAY 12:
5-9-18:
TC: 26700
RFT: UREA: 115, CREATININE: 2.2
Hb: 7.3
PR:128/min, bp:80/60mmhg, RR:28/min

49. 5-9-18:
CST
+
Tab ivabrad 5mg bd
Nebulization levolin
Inj atropine o.6mg iv stat
Inj adrenaline 1 mg iv repeated every 2to5mints
Death declared at 6:30pm on 5-9-18

50. 24.Tab ivabrad
MOA:Ivabrad 10 mg Tablet is a heart rate lowering medication. It
works by reducing the heart rate which lowers the oxygen
requirement of the heart. As a result, heart works more efficiently.
ADRS:
 Slow heart rate
 Headache
 Luminous phenomena
25.Inj atropine
MOA:Atropine Sulphate Injection is an anticholinergic medication.
It works by blocking the activity of a chemical messenger
(acetylcholine). This helps dry up secretions (saliva, sweat, etc.)
from glands before surgery, increases a low heart rate and
decreases intestinal contractions (spasms). It also works as an
antidote in certain types of poisoning and reverses the side effects
of certain muscle relaxing medicines.
ADRS:
 Blurred vision
 Increased heart rate
 Dryness in mouth

51. 26.Inj adrenaline:
MOA:Adrenaline/Epinephrine is an alpha- and beta-
adrenergic agonist. It relaxes muscles in your lungs and
relieves spasm, wheezing, and shortness of breath that
occurs during a severe allergic reaction (anaphylaxis).
ADRS:
 Headache
 Restlessness
 Tremor
 Palpitations

52. CPR NOTES:
 Patient had bradycardia followed by cardiac arrest , CPR was
intiated immediately as per ACCS guidelines with 5 cycles of
CPR given but not achieved. Death at 6:30 pm @ 5/9/18.
Cause of death:
Septic shock with MODS , burns –bilateral lower limbs

53. PATIENT COUNSELLING:
Burn rehabilitation is an undeniably difficult and time
consuming effort that, to attain the objective of
optimal long-term function, must begin at the outset
of burn care.
Treatment goals and strategies vary, depending on
the patient's injury, stage of treatment, age, and
comorbidities.
Goals range from minimizing loss of range of motion
(ROM) in the critically ill patient to establishing a
work-hardening program in recovered patients.

54. Goals of nutritional management
 To promote optimal wound healing and rapid recovery from burn injuries
 To minimise risk of complications, including infections during the treatment
period
 To attain and maintain normal nutritional status
 To minimise metabolic disturbances during the treatment process
Objectives of nutritional management
 Provide nutrition via enteral route within 6 - 18 hours post burn injury
 Maintain weight within 5 % - 10 % of pre-burn weight
 Prevent signs and symptoms of micronutrient deficiency
 Minimise hyperglycaemia
 Minimise hypertriglyceridaemia
Historically, about half of all burns were deemed preventable. Burn prevention
programs have significantly decreased rates of serious burns. Preventive
measures include: limiting hot water temperatures, smoke alarms, sprinkler
systems, proper construction of buildings, and fire-resistant clothing. Experts
recommend setting water heaters below 48.8 °C (119.8 °F). Other measures to
prevent scalds include using a thermometer to measure bath water
temperatures, and splash guards on stoves. While the effect of the regulation of
fireworks is unclear, there is tentative evidence of benefitwith
recommendations including the limitation of the sale of fireworks to children.

55. PHARMACIST INTERVENTION:
ADRS WHICH HAVE BEEN NOTICED IN CASE SHEET:
30/8/18: hypokalemia due to zymoflam <> dytor
1/9/18: zymoflam<> fragnim – increase risk of bleeding
complications
2/9/18: ancool<> tramadol – bradycardia
3/9/18: ascoril<>linezolid –aspiration pneumonia
5/9/18: death

56. THANK YOU