CASE PRESENTATION

UTI with IBD-ulcerative colitis.

byNagaraju B

dr.bnr2011@gmail.com

DEMOGRAPHIC DATA

Patient Name - xxxIP No. - 9857/13DOA - 28/10/2013DOD - 30/10/2013Ward - Med-IAge - 23years Sex - Male

SUBJECTIVE EVIDENCE

Chief complaint/ History of Presenting illness: c/o fever with chills since 3 days c/o severe headache and generalized

body pains since 3 days c/o generalized weakness and fatigability

since 3 days c/o dysuria for 1 week and it was

subsided 3 days back

Previous history: h/o Irritable Bowel Disease-Ulcerative

Colitis(IBD-UC) since 3 years with on medication, 1) Tab Mesacol 800mg (TID) 2) Tab Wysolone 25mg (OD)

No h/o prior other comorbidities No h/o DM/HTN/IHD/TB/Epilepsy

Past Medication History with Allergy: Nothing significant

Personal history: Diet- MixedAppetite- DecreasedSleep- DisturbedBowel- Constipation+Bladder- irregular Habits- None

Family history:

no f/h/o DM, HTN, ASTHMA, TB

OBJECTIVE EVIDENCEPhysical examination:A 23 year old male patient moderately built, conscious, cooperative and alert.

Vital signs:

BP-120/70 mmHg

PR-84 bpm

RR-17cpm

Temp-afebrile

P[-], I[-], C[-], C[-], L[-], E[-]

Systems :

P/A -soft, non-tenderness.

RS -NVBS+, no additional sounds.CVS – S1S2+, no murmurs.

CNS -HMF-N

cranial nerves-N

No sensory/motor deficit

Provisional diagnosis :

??UTI with IBD

TEST TEST VALUE NORMAL VALUE

Hb (g/dl) 14.0 12-16

TLC(cells/cmm)

15700 4000-11000

DLC N (%) 90

40-75

L (%) 07 20-45

E (%) 00 1-6

M (%) 03 2-10

B (%) 00 0-1

Platelets (cells/cmm) 1.84 1.5-4.0 lakh/cmm

PCV(%) 38.2% 42-52

LABORATORY INVESTIGATIONS:

TEST TEST VALUE NORMAL VALUE

Bl. U (mg/dl) 19 12-40mg/dl

Sr. Cr (mg/dl) 0.9 0.2-1.4mg/dl

Sodium (mmol/L) 134 135-145

Potassium (mmol/L) 2.9 3.5-5.0

Chloride (mmol/L) 111 96-106

Urine Microscopy Numerous pus cells are seen

USG Abdomen Debris in bladder is seen

ASSESSMENTBased on subjective evidence[fever, body pains, headache, dysuria, weakness and fatigability] & objective evidence [elevated WBC count and Neutrophil percentage, numerous pus cells in the urine and debris has seen in the bladder as per USG report], the patient was diagnosed to have Urinary Tract Infection with Irritable Bowel Disease [Ulcerative Colitis]

MEDICATION CHART:BRAND NAME GENEROIC NAME DOSE FREQUENC

YDATE DATE

END

Inj Mikacin AMIKACIN 750mg

1-0-0 28/10

Contd/-

Inj Febrinil PARACETAMOL 125mg

sos 28/10

Contd/-

Tab Dolo 650 PARACETAMOL 650mg

1-1-1 28/10

Contd/-

Tab Mesacol MESALAZINE 800mg

1-1-1 28/10

Contd/-

Tab Wysolone PREDNISOLONE 25mg 1-0-0 28/10

Contd/-

Inf NS SOD CHLORIDE 2PINT 75-125ML 30/10

Contd/-

DATE SHEET [PROGRESS NOTE]:First day [ 28-10-2013 ] O/E : Pulse-84/min BP-120/70mmHg CVS- S1S2 + Temp-normal No pallor/Icterus P/A-NADAdvice : Inj.Amikacin 750mg [1-0-0] Inj.Febrinil (Paracetamol) 125mg [OD] Tab Dolo (Paracetamol) 650mg [1-1-1] Tab Wysolone (Prednisolone) 25mg [1-0-0] Tab Mesacol (Mesalazine) 800mg [1-1-1] IVF-NS 75ml /hr

Second day [ 29/10/2013 ]DysuriaFrothy urine

Advice : Inj.Amikacin 750mg [1-0-0] Tab Dolo (Paracetamol) 650mg [1-1-1] Tab Wysolone (Prednisolone) 25mg [1-0-0] Tab Mesacol (Mesalazine) 800mg [1-1-1]

Third day [ 30/10/2013 ] Patient feels better & CST Advice : N.S 125mg/hr Inj.Mikacin (Amikacin) 750mg [1-0-0] Tab Dolo (Paracetamol) 650mg [1-1-1] Tab Mesacol (Mesanisolazine) 800mg [1-1-1] Inj.Febrinil (Paracetamol) 125mg sos Tab Wysolone (Prednisolone) 25mg [1-0-0] Syrup Potklor (Pot. Chloride) 15ml [TID]

PLANNING

Suggestion to Physician- No drug interaction found. Urine culture and sensitivity tests and Blood

sugar tests might have advised.

Advice to Patient- Adhere to medication. Practice good hygiene. Drink plenty of water and other fluids to flush the urinary

system. Empty bladder after sex. Wash your genital area or shower before sexual activity. Go to the toilet as soon as you feel the urge to urinate,

rather than holding on. Wipe yourself from front to back (urethra to anus) after

going to the toilet Avoid using spermicide-containing products, particularly

with a diaphragm contraceptive device. Wear cool cotton underwear, rather than a synthetic

material to help with ventilation. 

THANK YOU…