CASE PRESENTATION ON

URINARY TRACT INFECTION

NAME: K. SANDHYA
ROLL NO:17CM1T0015
PULLAREDDY INSTITUTE OF PHARMACY
DOMADUGU,SANGAREDDY DIST.
DATE: 03/12/2018
 CASE STUDY
PATIENT INFORMATION
• PATIENT NAME: Ms. X
• AGE: 35yrs
• SEX: F
• IPNo.:2018110208
• DOA: 01/11/2018
• DOD: 04/11/2018
•CHIEF COMPLIANTS:fever with chills, mild cough,
headache, pain in abdomen, nausea, severe body pains, loss of
appetite and swelling in perineal region.

•O/E:
• Temp:Afebrile
• P.R: 86bpm
• C.V.S: S1 S2+
• R.S: Clear
• R. R: 20 / min
• P/A: Soft
• CNS: NAD
 LAB INVESTIGATIONS
TEST RESULT REFERENCE
RBS 61mg/dl 80-130mg/dl
WBC 5,700cells/ cumm 4,000-11,000cells/cumm

Platelet count 2.1lakhs/ cmm 1.5-4.5 lakhs/cmm

ESR 15 mm/hr 0-29 mm/hr

PUS cells 5-8 0-5

Serum creatinine 0.7 mg/dl 0.6-1.1mg/dl

Blood urea 22 mg/ dl 7-20 mg/dl

T. S. H 3.08mlU/l 0.4-4.2 mlU/l

Liver function test Normal -

Widal test Normal -

ON DAY 1:01/11/18 Rx
•C/O: fever with chills, mild • IVF RL and NS
cough, headache, pain in • Inj.amonic 1.2mg IV BD
abdomen, nausea, severe • Inj.Pan 40mg IV BD
body pains, loss of appetite . • Inj.Zofer 4mg IV SOS
•O/E: Pt:C/C,Temp: Afebrile • Tab. Calpol 650mg PO SOS
BP: 120/80mmHg • Tab. Meftal spas PO BD
PR: 86bpm • syp. Mucaine gel 10ml PO TID
CVS:S1S2+ • syp.KUFRIL-LS 10ml PO BD
P/A: Soft • Tab.ZERODOL-CR 200mg PO
ON DAY 2:02/11/18 BD
• Syp. Cital 15ml PO TID
•C/O: cold,throat irritation,
swelling in perineal region. Rx
•O/E: Pt:- C/C,Temp:Afebrile
BP: 100/80mmHg • C.S.T
PR: 80bpm
RR: 20/min
ON DAY 3 :03/11/18
•C/O:Fever in the evening, dry Rx
cough, sore throat, Dysuria, burning ● C. S. T
urunation, nausea and swelling at +
urethral region. ● Tab. Vitency PO OD
•O/E:Temp: 98.6°F
PR: 50bpm
BP: 110/70mmHg
H/L: NAD
ON SAME DAY @9.30Pm
Rx
•C/O: evng raise of fever, burning
● C. S. T
urination, dysuria.
•O/E:Temp:102.8 F
PR :82bpm
BP :110/70mm Hg
CVS. : S1S2+
● ON DAY 4:04/11/18 Rx
● C/O :- No fresh ● C.S.T
complaints. Burning
micturition, body pains
● O/E: Pt: Afebrile
PR: 80bpm
Resp: Clear Discharge medication:-
CVS: S1S2+ • Tab. Calpol 650mgPO BD
BP:110/70mmHg • syp. Mucaine gel PO BD
• syp.KUFRIL-LS 10mlPO BD
Discharge summary:-patient •tab. ZERODOL -CR 200mg PO
was feeling better can be BD
discharged •Syp. cital 15ml PO BD
• tab. Vitency PO BD
 DRUG CHART
Drug name Generic Dose Frequenc ROA Category
name y

Inj.Amonic Amoxicillin+ 1.2gm BD IV Antibiotic

clavulanic acid (penicillin)

Inj. pan Pantoprazole 40mg BD IV PPI

Inj.zofer Ondansetron 4mg BD IV Anti-emetic

Tab. Calpol Paracetamol/Acet 650mg SOS PO Anti-pyretic and analgesic

aminophen

Tab. Meftal Dicyclomine+Mef 500mg BD PO Anti-spasmodic

spas enamic acid

Syp. Mucaine Oxethazaine+ 10ml TID PO Antacid with local

gel aluminium anaesthetic
hydroxide+ milk
of magnesia
Drug name Generic name Dose Frequency ROA Category

Syp. Kufril-LS Ambroxol+ 10ml BD PO Expectorant

levosalbutamol/leva
lbuterol+
guaifenesin

Tab. Zerodol Aceclofenac 200mg BD PO NSAID

-CR

Syp. Cital Disodium hydrogen 15ml TID PO Anti-oxidant

citrate

Tab. Vitency Multivitamins+ OD PO Nutritional

multiminerals+ supplement
folic acid+ calcium
pantothenate
 PRESCRIPTION ANALYSIS
• SUBJECTIVE EVIDENCE:
A Female patient of age 35yrs admitted in
Female general ward holding IP NO:-2018110208 with
complaints of Severe body pains,fever with
chills,dysuria,mild cough,abdominal pain, nausea and loss of
appetite on 01/011/2018.
• OBJECTIVE EVIDENCE:
Random blood sugar levels: 61mg/dl., PUS cells: 5-8
Blood urea: 22mg/dl
• ASSESMENT: Based on the subjective and objective
evidences the patient was diagnosed with Urinary tract
infection.
 PLAN
•ON DAY 2:
•ON DAY 1:
Rx
Rx
•C.S.T
● IVF RL and NS
•Inj.Amonic 1.2gm IV BD
•ON DAY 3 :
•Inj.Pan 40mg IV BD
Rx C.S.T
•inj.zofer 4mg IV BD
+
•Tab.Calpol 650mg PO BD
Tab. Vitency PO OD
• Tab. Meftal spas PO BD
• Syp.Mucaine gel 10mlPO TID
•ON SAME DAY @9.30Pm :
• Syp. Kufril-LS 10ml PO BD
C.S.T
•Tab.Zerodol-CR 200mg PO BD
•Syp. Cital 15ml PO TID
•ON DAY 4:

Rx:
• C.S.T
DISCHARGE MEDICATION:
• Tab. Calpol 650mg PO SOS
• Tab. Zerodol-cr 200mg PO BD
• Tab. Vitency PO BD
• syp. Mucaine gel 10ml PO TID
• Syp.kufril-LS 10ml PO BD
● syp. Cital 15ml PO BD
REPORT:
All the drugs given are appropriate and the doses, frequencies of
drugs are correct
 PATIENT COUNSELLING POINTS
•PHARMACOLOGICAL POINTS:-
•mucainegel syrup should be taken before breakfast.
•zerodol-cr tablet should be taken without food or milk to
prevent upset of stomach.
•NON PHARMACOLOGICAL POINTS:-
•Drink plenty of fluids to help flush bacteria out of the urinary
tract.
•Get plenty of vitamin c. It makes urine acidic and helps keep
bacteria down.
• Empty your bladder completely as soon as you feel the urge,
or at least every three hours.

THANK YOU