case ppt on UTI with IBD
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Transcript of case ppt on UTI with IBD
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…
