This patient, a 33-year-old female, presented with abdominal pain and nausea/vomiting. Laboratory tests revealed cholelithiasis (gallstones), grade 1 fatty liver, elevated liver enzymes, and high cholesterol. An ultrasound confirmed gallstones and fatty liver. She was prescribed antibiotics, antacids, pain medications, vitamins, ursodeoxycholic acid, and amino acids to treat her conditions and improve liver function. Diet and lifestyle counseling focused on a low-fat, high-fiber diet and exercise to reduce cholesterol and fatty liver deposits.

1. CASE PRESENTATION ON
CHOLELITHIASIS WITH GRADE 1 FATTY LIVER
KAVIYA AP
PHARM D
RA1522281010017

2. SUBJECTIVE EVIDENCE
• A female patient of age 33 years was admitted in the
general ward on Oct 21st 2018
• With the chief complaints of abdominal pain since 4
hours and nausea and vomiting for 1 week
• H/O Severe abdominal pain , bloating and indigestion
• No C/O Chest pain / palpitation

3. PAST MEDICAL HISTORY K/C/O Hypertension for 5 years
PAST MEDICATION
HISTORY
T.Inderal [ Propanolol ] 20mg
PERSONAL HISTORY Sleep pattern-normal
Loss of appetite
Loss of weight ( 7 kg reduced )
Disturbances in bowel and Bladder habit
Regular mensus
FAMILY HISTORY No relevant family history

4. GENERAL EXAMINATION O/E: Conscious, oriented.
TEMP: 98.7 F CVS : S1S2+
BP : 110/80 mm Hg CNS : NFND
PR : 72 b/min RS : B/L AE+
RR : 36 cycle/min P/A : Epigastric
tenderness
INVESTIGATIONS DONE Complete blood count
Liver function test
Renal function test
USG abdomen
Urine analysis
Sr Electrolytes

5. OBJECTIVE EVIDENCE
PARAMETERS OBSERVED RANGE NORMAL RANGE
Hb 10.7 11.5-16.5 g/dl
PCV 32 40-50%
TOTAL RBC COUNT 3.8 4.5-5.5 m/cumm
TOTAL WBC COUNT 7.1 4000-11000/cumm
NEUTROPHILS 68.4 40-80%
LYMPHOCYTES 27 20-40%
ESR 58 0-10 mm/hr
MCH 27 27-32 pg
MCV 32 83-101 fl
SODIUM 134 130-145 mmol/L
CHLORIDE 121 95-105 mmol/L

6. PARAMETERS OBSERVED VALUE NORMAL RANGE
TOTAL BILIRUBIN 1.7 0.5-1.0 mg/dl
DIRECT BILIRUBIN 0.5 upto 0.3 mg/dl
INDIRECT BILIRUBIN 1.3 0.2-0.7 mg/dl
TOTAL PROTEIN 6.7 6.0-8.0 g/dl
ALBUMIN 4.0 3.5-5.0 g/dl
GLOBULIN 2.7 2.5-3.0 g/dl
ALBUMIN/GLOBULIN RATIO 1.5 1.2-1.5
SGOT(AST) 411 5-40 U/L
SPOT(ALT) 383 5-35 U/L
ALKALINE PHOSPHATE 359 40-125 U/L
GAMMA GT 247 10-50 U/L

7. PARAMETERS OBSERVED VALUE NORMAL RANGE
LIPID PROFILE TEST
CHOLESTEROL 218 < 200 mg/dl
TRIGLYCERIDES 125 40-150 mg/dl
HDL 41 > 40 mg/dl
LDL 127 80-150 mg/dl
VLDL 25 <40 mg/dl
TOTAL CHOLESTEROL 5 3-5

8. DATE SPECIAL INVESTIGATIONS IMPRESSION
22.10.18 URINE ANALYSIS :
colour : yellow
appearance : clear
reaction : -
albumin : nil
epithelial cell : 1-2 cells
pus cells : Occasional
Normal
22.10.18 ULTRASOUND REPORT :
LIVER : Normal in size and shows
Increased echo texture.
GALL BLADDER : Mild GB wall edema
two calculi of 5mm are found
NOTE : Organised collection 34x26 mm seen in the
epigastric region below the stomach
Fatty liver
Cholelithiasis
22.10.18 MICROBIOLOGY REPORT :
Scanty growth of urethral commensal Infection

9. ASSESSMENT
FINAL DIAGNOSIS
Cholelithiasis
 Grade 1 - Fatty liver

10. THERAPEUTIC GOALS
To bring the normal function of the liver.
To monitor the electrolytes level in the body.
To avoid further complications of the liver.
To improve the quality of life of the patient.
PLAN

11. S.N DRUG NAME GENERIC NAME DOSE ROA FREQ DAYS
1 2 NS Normal saline I.V OD 1-9
2 Inj.Taxim CEFOTAXIME 1g I.V BD 1-9
3 Inj.Metro METRONIDAZOLE 500mg I.V BD 1-9
4 Inj.pan PANTOPRAZOLE 40mg I.V OD 1-9
5 Inj.Emeset ONDANSETRON 4mg oral BD 1-9
6 Inj.Tramadol TRAMADOL 100mg I.V 1-0-1 1-9
7 Inj.MVI VITAMIN SUPPLEMENT 10ml I.V 1-0-0 3-9
8 T.Udiliv URSODEOXYCHOLIC ACID 500mg oral OD 3-9
9 C.Astymine Forte AMINO ACIDS +
VITAMINS
oral OD 3-9

12. According to the standard guidelines,
There is no interactions found in the prescription.
DRUG INTERACTION

13. PHARMACIST INTERVENTION
• Since the Hb levels of the patient is low iron supplements can be prescribed.
• There is increased chloride level in blood , indicates patient is dehydrated. It
can also lead high Na content in blood and cause kidney problems so
continous monitoring of electrolytes and low Na diet is must.
• High cholesterol level is reported. Therefore use of statins is safer and can
improve liver test.

14. DISEASE COUNSELING
• Cholelithiasis is the formation of hardest deposit in the fluid
within the gall bladder.
• Decreasing the cholesterol content in the bile can easily dissolve
the gall stones.
• A high fiber , low fat diet helps to keep bile cholesterol level in
normal form.
• Rapid loss of weight can develop gall stones. Therefore get
counseling from dietician and improve normal weight.

15. DRUG COUNSELING
• T.Udiliv can cause discolouration of urine and black tarry stools. Do not
panic if these symptoms are seen.
• Take vitamin tablet in the morning, since they are synthetic substances
they are well absorbed when taken with food. Taking them at night can
interfere with sleep.
• Do not stop the course of antibiotics even if you are feeling better.if
treatment stops soon the remaining bacteria become resistant to the
antibiotic taken.

16. DIET COUNSELING
• Follow DASH diet.
• Weekly consume omega 3 fatty acid containing foods like salmon
and tuna fish ,as they reduce LDL level.
• Garlic is a staple in many diets, consumption of that is beneficial
for reduction of fatty liver disease.
• Potassium rich foods like banana , kiwi , milk and yogurt helps in
protecting liver from fatty deposits.
• Avoid foods and drinks that contain sugar especially fructose.
• Take carrot and beetroot juice in diet.

17. LIFESTYLE MODIFICATION
• Keep the body from dehydrating. Drink plenty of water.
• Clean the tube incised area with soap water gently and shower can
be taken regularly.
• Call healthcare provider when there is any yellowing of skin , belly
pain, rectal bleeding , swelling of legs and shortness of breath.
• Get enough sleep which is useful for build up of new RBC cells.
• Exercise regularly. Walk atleast 15 mins a day.
• Daily drink a glass of warm water with lemon and honey . It can
detoxify liver and helps it function normally.

18. Thank you