Case prrsentation

1. 38091834

2.  A male patient of age 38yrs presents to the physician
with the complaint of painful micturition, fever, chills
and rigors for 5 days and vomiting , headache,
abdominal pain for 1 week.

3. PATIENT DETAILS
NAME: Mr. X
AGE 38 yrs
SEX MALE
IP NO 20105626
DEPT GM
WEIGHT 62KG
HEIGHT 5’2”
DOA 22/9/2010
DOD 28/9/2010

4.  PRESENTING COMPLAINTS
C/o painful micturition, fever, chills and rigors for 5
days and vomiting , headache and abdominal pain for 1
week.
 PAST MEDICAL HISTORY
K/C/o IHD
 PAST MEDICATION HISTORY
T.Atorvastatin 10 mg
T.Aspirin 75 mg

5.  SOCIAL HISTORY
Alcoholic
Smoker
Married
 PREVIOUS ALLERGIES
No specific allergies.

6. Vital signs:
Date 22/9 23/9 24/9 25/9 26/9 27/9 28/9
Temp 100 101 101 100 99 99 99
BP 190/10
0
150/100 150/100 140/100 140/90 140/90 140/90
Pulse 89 85 80 82 82 82 82

7. Biochemical investigation
 BLOOD COUNTS:
 Hb: 14.5 mg/dl
 TLC: 6,300 cells/cumm
 ESR: 12mm/hr
 DLC (%)
Polymorphs: 57
Lymphocytes: 28
Basophils: -
Eosinophils: 2
Monocytes: 1
 BLOOD SUGAR (MG %)
 FBS-120 mg/dl
 PPS-250 mg/dl
 RBS-120 mg/dl
 Renal function test:
 Urea – 49 mg/dL
 Uric acid-2.5 mg %
 Sr.creatinine-1.8mg %

8.  Urine examination:
colour: pale yellow
bile salts: -ve
bile pigment: -ve
Albumin: ++
pus cells: 10-15
 Organism isolated:
E-coli in colony
sugar: ++
WBC: 5-6
RBC: 6-8
casts: nil
epithelial cells: 3-4
 Other investigation:
PSA: 0.86 ng/ml

9. FINAL DIAGNOSIS
 UTI/ BPH

10. DRUGS PRESCRIBED:
S.NO DRUGS DOSE DATE OT TREATMENT
T.NAME G.NAME 22/9 23/9 24/9 25/
9
26/9 27/9 28/9
1 INJ.AUGMENTIN AMOXICILLIN
+CLAVULANIC
ACID
1.2g
BD
√ √ √ √ √ √ √
2 T.URIKIND FLAVOXATE 200 mg √ √ √ √ √ √ √
3 INJ.AMIKACIN AMIKACIN 500 mg BD √ √ √ √ √ √ √
4 T. PAN 40 PANTAPRAZOLE 40 mg
BD
√ √ √ √ √ √ √
5 INJ.TRAMAZAC TRAMADOL 100 mg
BD
√ √ √ √ √ √ √
6 C. DYNAPRESS TAMSULOSIN 0.4mg
OD
√ √ √ √ √ √ √

11. Subjective
Objective
Assessment
Plan

12. PROBLEM LIST
1. Urinary tract infection
2. Benign prostate hyperplasia

13. SOAP NOTES FOR URINARY TRACT
INFECTION
Subjective:
C/o painful micturition

14. Objective :
K/C/o IHD
Urine examination:
 colour: pale yellow
 Albumin: ++
 pus cells: 10-15
 WBC: 5-6
 RBC: 6-8
 Epithelial cells: 3-4

15. Assessment :
Diagnosis:
o Urinary tract infection.
Etiology :
 Presence of E-coli
 Indication for therapy:
To prevent further complications.

16. Assessment of current therapy:
 1. Inj Augmentin ( amoxicillin + clavulanic acid) 1.2g
BD
• 2. Urikind ( flavoxate ) 200mg BD
• 3. inj.amikacin 500 mg BD
• 4. T.Pan 40 ( pantoprazole) 40 mg BD
• 5.Inj. Tramazoc ( Tramadol ) 100mg BD

17.  Alternate therapy:
1. Bacteriostatic agents: sulphonamide, tetracycline,
nitrofurantoin
2. Bactericidal agents: coltrimoxazole, cephalosporin, FQ’S.
3. Urinary antiseptics: nitrofurantoin, methanamine,
nalidixic acid

18. Plan:
 Discharge medication:
 C.Proxyvon 1-0-1
 T.Flavoxonate 200mg 1-1-1
 T.Amoxicillin/clavulanate 625mg 1-0-1
 C.Dynapress 0.4 mg 0-0-1
 Goals of therapy:
 General goal:
To reducefrequency , duration and severity of
infection.

19.  Patient specific:
 To relieve pain during micturition.
 To improve quality of life.
 Goals achieved:
 Symptoms got relieved.
 Monitoring parameters:
• Urine examination ,urine culture.
• Toxicity parameters:
• Check for diarrhoea, dizziness(pantoprazole), nausea,
vomiting(tramadol), hypersensitivity
reactions(amikacin).

20.  Points to physician:
Monitor all parameters
Check ADR
 Points to the patient:
About disease:
UTI due to presence of bacteria.
About drugs:
Take all medications as prescribed.
In case of hypersensitivity contact your physician.

21.  LIFESTYLE MODIFICATION:
 Drink plenty of water to keep urinary tract flushed
 Urinate before and after sexual intercourse
 Wash hands before and after urination
 Urinate when you feel the need.
 Avoid caffeine & alcohol
 FOLLOW UP
Review after 15 days with urine culture report.

23. SOAP NOTES FOR BPH
Subjective : painful micturition
Objective:
 PSA- 0.86 ng/ml
 Assessment:
Diagnosis:
 BPH
• Etiology:
• E-Coli

24.  Indication for therapy
 Painful micturition and presence of pus cells & E-Coli.
 Assessment of current therapy:
 1.C.Dynapress ( Tamsulosin) 0.4 mg OD

25.  Alternate therapy:
 Non selective alpha 1 adrenergic antagonist
a) Short acting: prazosin, indoramin.
b) Long acting: terazosin, doxazosin.
• GnRH antagonist: antiandrogens-5 alpha reductase
inhibitor-finasteride.

26. Plan:
 Discharge medication:
 C.Dynapress 0.4 mg 0-0-1
 Goals of therapy:
 General goal:
To prevent frequent nocturnal micturition
To maintain normal sex life.
To reduce pain and discomfort.

27.  Patient specific:
To relieve pain during micturition .
To improve quality of life.
 Goals achieved:
 Symptoms got relieved.
 Monitoring parameters:
 urine culture, PSA test, pus cells
• Toxicity parameters: check For postural
hypotension. Vetrigo, ejeculation(dynapress)

28.  Points to physician:
Monitor all parameters at the time of discharge.
Watch for ADR
 Points to the patient:
About disease:
BPH due to presence of bacteria
About drugs:
Take medication as prescribed.
If any ADR noticed like abnormal ejaculation contact
your physician immediately.

29.  LIFESTYLE MODIFICATION:
 Reduce intake of coffee, tea, cola drinks.
 Eat dinner in the early evening for eliminating fluids
 Drink glasses of water to prevent accumulation of
bacteria
 avoid prolonged sitting
 Adhere to the medications.
 FOLLOW UP
Review after 15 days with report of PSA test & urine
culture test.