SOAP CASE PRESENTATION ON ACUTE GASTRO ENTRITITIS WITH DIABETES MELLITUS AND HYPERTENSION.

1. CASE PRESENTATION ON
ACUTE GASTRO ENTERITITIS WITH
DIABETIS MELLITUS WITH
HYPERTENSION.
PRESENTED BY-
Ms. VARSHA R WADNERE
{PD539}

2. • SOAPANALYSIS
Patient Details-
• Patient Name- ABC
• IPN NO- IPD-1-220xxxx
• Ward- General Medicine Male 404
• Date of Admission- 01-10-2022
• Date of Discharge- 04-10-2022
• Age- 58 years old
• Gender- Male
• Height- 162 CMS
• Weight- 68 kg
• BMI- 20.0 kg/m2 (Normal 18.5- 25)

3. • SUBJECTIVE DATA
• Chief Complaints-
Loose stool following meals since 8 days, 2-3
episodes/day, non-bloody watery stool, fever 4 days
back- intermittent.
• Personal History-
Patient has been hospitalized before and received
blood transfusion.
• Medical History- Diabetes Mellitus type II and
Hypertension, since 2 years on medication.
• Medicine History- N/A
• Diet- Diabetic bland diet, energy- 1750kcal/day,
protein- 60g/day

4. • OBJECTIVE DATA
LAB REPORTS-
• 2D ECHO/ COLOR DOPPLER-
Mild concentric LV Hypertrophy.
• USG Abdomen and Pelvis-
Hepatomegaly with grade II Fatty liver.
• Blood group- O positive
• HbA1C Hb- 7.30
• Hb- 11.80
• PCV- 36
• MCV- 76.90
• MCH- 25.10
• RDW- 16.60
• PUS CELLS- 2-3/hpf
• Protein traces- present
• Glucose- present 2+
• Bile pigment- not significant

5. Drug Chart-
(DAYS)
1)INJ. MONOCEF- 1G-1-0-1- IV- (1-4)
CATEGORY- CEPHALOSPORIN Antibiotic
INDICATION- used to treat bacterial infections in
your body.
MOA- works by inhibiting the mucopeptide synthesis
in the bacterial cell wall.
ADR- diarrhoea, rash, and changes in liver function
tests and blood cell counts.
CONTRAINDICATIONS- liver problems, disease of
the gallbladder, severe renal impairment.
2)INJ. METRO- 100MG- 1-1-1- IV- (1,2)
CATEGORY- Nitroimidazole antibiotic
INDICATION- used to treat infections of the
gastrointestinal (GI) tract, skin, heart, bone, joint,

6. lung, blood, nervous system, and other areas of the
body.
MOA- diffuses into the organism, inhibits protein
synthesis by interacting with DNA, and causes a loss
of helical DNA structure and strand breakage.
ADR- stomach pain, hot flushes, difficulty breathing,
a pounding heartbeat (palpitations) and headaches.
CONTRAINDICATIONS- Psychotic Reaction with
Disulfiram, Interaction with Alcohol, Cockayne
Syndrome.
3)INJ. PAN-40MG- 1-0-0- IV- (1-4)
CATEGORY- proton pump inhibitor
INDICATION- used to treat acidity.
MOA- suppresses the final step in gastric acid
production by forming a covalent bond to two sites
of the (H+, K+)-ATPase enzyme system at the
secretory surface of the gastric parietal cell.
ADR- increased thirst, urination, hunger, stomach
pain.
CONTRAINDICATIONS- patients with a history
of hypersensitivity to the drug itself

7. 4)INJ. EMSET- 4MG- SOS- IV- (1-4)
CATEGORY- anti emetic
INDICATION-prevent nausea and vomiting
MOA- It works by blocking the action of a chemical
messenger (serotonin) in the brain that may cause
nausea and vomiting during anti-cancer treatment
(chemotherapy) or after surgery.
ADR- constipation, diarrhoea, fatigue and headache
CONTRAINDICATIONS- allergic to Ondansetron
5)INJ. OPTINEURON- 1AMP IN 100ML NS- 1-0-
0- IV- (1-4)
CATEGORY- B complex vitamin supplement
INDICATION- the treatment of Nutritional
deficiencies, Vitamin B12 deficiency.
MOA- nutritional supplement and helps to improve
the level of vitamin B12 in your body.
ADR- diarrhoea, tiredness, headache, nausea,
sleepiness
CONTRAINDICATIONS- bleeding in the
intestine, blockage in the stomach or intestine,
heart disease

8. 6)T. SHELCAL- 500MG- 0-1-0- ORAL- (1-4)
CATEGORY- nutritional supplement
INDICATION- to prevent and treat calcium
deficiency
MOA- works to protect and maintain bone health
ADR- hard stools, constipation, stomach upset
CONTRAINDICATIONS- History of Renal
Calculi, Hypercalcemia, Hypophosphatemia.
7)C.VIT D3 60 IU/ WEEK X 6 WEEK- 0-1-0- (1-
4)
CATEGORY- nutritional supplement
INDICATION- to treat vitamin d deficiency
MOA- maintenance of normal levels of serum
calcium and phosphorus in the bloodstream by
enhancing the efficacy of the small intestine to
absorb these minerals from the diet
ADR- chest pain, feeling short of breath, weakness
CONTRAINDICATIONS- high amount of calcium
in the blood, excessive amount of vitamin D in the
body, kidney stones.

9. 8)T. FORXIGA 10MG- 0-0-1- (1,2)
CATEGORY- Sodium-glucose co-transporter 2
(SGLT2) inhibitors
INDICATION- treatment of insufficiently
controlled type 2 diabetes mellitus as an adjunct to
diet and exercise
MOA- blocks reabsorption of filtered glucose in
the kidney, increasing urinary glucose excretion
and reducing blood glucose levels.
ADR- dizziness, confusion, feeling very thirsty,
less urination.
CONTRAINDICATIONS- hypersensitivity
reaction to FARXIGA, Severe renal impairment
9)T. TENEBETIC- 20MG- 1-0-0- (1-4)
CATEGORY- anti- diabetic, dipeptidyl peptidase-4
inhibitors
INDICATION- used to control sugar levels in
blood
MOA- increasing the release of insulin from the
pancreas and decreasing the hormones that raise
blood sugar levels.
ADR- Headache, Constipation, Dizziness.

10. CONTRAINDICATIONS- ketosis, diabetic coma,
hypoglycaemia
10) T. TELMIKIND- 40MG-1-0-0-(1-4)
CATEGORY- angiotensin II receptor antagonists.
INDICATION- used to treat high blood pressure
MOA- blocking the hormone angiotensin, thereby
relaxing the blood vessels
ADR- dizziness, headaches, and nausea
CONTRAINDICATIONS- allergic to its
components
11) T. GASEX- (1)
CATEGORY- Anti-flatulent.
INDICATION- used to relieve symptoms of extra
gas such as belching, bloating
MOA- An anti-flatulent that changes surface
tension of gas bubbles, allowing easier elimination
of gas.
ADR- nausea, GI problems, edema
CONTRAINDICATIONS- if you are allergic to it

11. 12) T. DUCOLAX- (1)
CATEGORY- laxative.
INDICATION- to treat constipation
MOA- bisacodyl stimulates, after hydrolysis in the
large intestine, peristalsis of the colon and
promotes accumulation of water, and consequently
electrolytes, in the colonic lumen.
ADR- abdominal pain or cramping, nausea,
diarrhoea, or weakness
CONTRAINDICATIONS- ileus, intestinal
obstruction
13) T. DAPA- MG- 0-0-1- (3,4)
CATEGORY- SGLT2 inhibitors
INDICATION- improve glycemic control
MOA- blocks reabsorption of filtered glucose in
the kidney, increasing urinary glucose excretion
and reducing blood glucose levels
ADR- swelling in your feet or ankles, feeling tired
or short of breath
CONTRAINDICATIONS- diabetic ketoacidosis

12. 14) INJ. METROGYL- 100ML-IV- (3,4)
CATEGORY- Nitroimidazole Antibiotic
INDICATION- stops growth of bacteria
MOA- diffuses into the organism, inhibits protein
synthesis by interacting with DNA, and causes a
loss of helical DNA structure and strand breakage.
ADR- stomach pain, hot flushes, difficulty
breathing, a pounding heartbeat (palpitations) and
headaches
CONTRAINDICATIONS- Psychotic Reaction with
Disulfiram, Interaction with Alcohol, Cockayne
Syndrome.
15) IVF. NS/RL@ 60 ML/HR- (1-4)
CATEGORY- Crystalloid Fluid
INDICATION- balance electrolytes in body
MOA- control of water distribution, fluid and
electrolyte balance and osmotic pressure of body
fluids.
ADR- hypervolemia, infection at the site of
injection.
CONTRAINDICATIONS- edema, heart disease

13. • ASSESSMENT
• Provisional Diagnosis-
Acute gastro enteritis with diabetes mellitus with
hypertension.
• Diagnosis-
Acute gastro enteritis with diabetes mellitus with
hypertension.

14. • Progress chart-
1/10/22-
S/E-
CNS- Conscious, Oriented, Afebrile
CVS-S1S2+
R/S- BAE+
P/A- SOFT
PR- 78/min, BP- 120/80mmHg
2/10/22-
S/E- conscious, oriented, afebrile
PR- 84/min, BP- 120/70mmHg
3/10/22-
S/E- conscious, oriented, afebrile
PR- 86/min, BP- 140/90mmHg
4/10/022-
S/E- conscious, oriented, afebrile
PR- 86/min, BP- 110/70mmHg

15. • Follow up details-
In medicine OPD no-1 on Thursday under unit 6
after 2 weeks or SOS in case of emergency.
Follow up with investigations of BSL- F/PP.
• Discharge medications-
1) O2- 1-0-1X 3 DAYS
2)METFORMIN 500 MG- 1-0-1
3)DAPAGLIFLOZIN- 10MG- 0-1-0
4)TENILIGLIPTIN- 20MG- 1-0-0
5)TELMA-AM-5MG- 1-0-0
6)HOSIT X 0-1-0 X 1 MONTH
7)SHELCAL 500 MG 0-1-0X 1 MONTH
8)CAP. VIT D3 60K IU/WEEK X 6 WEEK
• Patient Compliance-
Patient didn’t have any complaints to the therapy
given.

16. INTERVENTION
• While prescribing, write generic name of the
drugs instead of brand names.
• INTERACTION-
BISACODYL AND SHELCAL (CALCIUM
AND VIT D3) NEED THERAPY
MODIFICATION, WHERE SEVERITY IS
MINOR.
MANAGEMENT- ANTACIDS SHOULD NOT
BE USED WITHIN 1 HOUR BEFORE
BISACODYL ADMINISTRATION.

17. MY PLAN-
PATIENT COUNSELLING-
• On drugs-
1)T.PAN 40- Consume 1 hr. before the meal.
2)ANTACIDS SHOULD NOT BE USED WITHIN
1 HOUR BEFORE BISACODYL
ADMINISTRATION.
• On disease-
Follow Diabetic diet.

18. • Lifestyle Changes-
• Maintain regular schedule for eating and sleeping
• Take medication on time, do not repeat dose if
missed
• Drink 7-8 glasses of water.
• Avoid Junk food.
• Consume protein rich foods- tofu, egg, chicken,
seafood, lentils.
• Consume whole grain and high fiber
carbohydrates- beans, cereals, whole grain chapati
• Consume non starchy vegetables- cauliflower,
tomatoes, peppers, cabbage, French beans.
• Consume 1:1 water and jamun and karela juice in
the morning on an empty stomach.

19. BRAND NAMES
PRESCRIBED DRUGS BRAND NAME
1)INJ. MONOCEF
2)INJ. METRO
3)INJ. PAN
4)INJ. EMSET
5)INJ. OPTINEURON
6)T. SHELCAL
7)C.VIT D3
8)T. FORXIGA
9)T. TENEBETIC
10) T. TELMIKIND
11) T. GASEX
12) T. DUCOLAX
13) T. DAPA
14) O2
15) METFORMIN
16) TELMA-AM
17) HOSIT

20. • REFERENCE
• LEXICOMP APP