2. Name : ABC
Age : 60 years
Sex : Female
Dept : General Medicine
3. C/o Fever with chills since 10 days
Dry cough since 10 days
Breathlessness ( on & off ) since 6 days
Burning micturation since 5 days
4. Medical history : History DM
Medication history : Metformin+Glimipride
Social history : Nothing significant
Family history : Nothing significant
Allergies : Nil known allergies
5. S - Subjective Evidence
O - Objective Evidence
A - Assessment
P - Planning
8. To maintain the body temperature
Resuscitate the patient using supportive measures to correct
the hypoxia condition.
To eradicate the organism from the body.
To prevent the complications associated with urosepsis.
9. S.I
NO
DRUGS
(Generic names)
DOSE ROA FRE DA DS
1 Normal saline 2 pint I.V - 1 2
2 Inj.Levofloxacin 500mg I.V B.D 1 2
3 Inj.Pantoprazole 40 mg I.V OD 1 2
4 Inj.Ondansetron 4mg I.V SOS 1 2
5 Tab.Paracetamol 650 mg P.O SOS 1 2
6 Syp.Disodium hydrogen citrate
with water
2 tbsp P.O T.I.D 1 2
10. DAYS PROGRESS
DAY
-1
O/E Patient is c/c
PR :82/min, B.P :110/70mmhg, R.S :BAE +
Lab data
Blood urea :30 mg/dl, Sr.creatinine :0.8 mg/dl, R.B.S :71 mg/dl
Na+:137 m.mol/L, K+:3.1 m.mol/L, Cl-:101 m.mol/L
C.U.E
Color:Pale yellow, R.B.C:NIL, Proteins :Trace, Pus cells : 2-4cells,
Glucose :Negative, Epithelial cells :6-8cells
Malarial parasite, Dengue, HIV Antibody, HBsAG: Negative
DAY-2 O/E: Pt is c/c, PR:76/min, BP:110/70mmhg, CVS:s1s2+, P/A:soft
LAB DATA
U.S.G Abdomen:No sonographic abnormalities were seen
Chest x Ray: No abnormalities detected
11. Body temperature is maintained
organism was eliminated from the body
No other complications associated with the disease
were seen
12. Closely monitor the vital signs like Heart rate,
Blood pressure, Respiratory rate, Urine output
and vigilance activity.
13. Drug – Drug interactions :
Levofloxacin < > ondansetron
MOA
May causes the prolongation of QT interval may result in
ventricular arrhymias including sudden death.
Management
Monitor the plasma levels of levofloxacin
Advice the patient about the symptoms of this DI
14. Discharge medications:
Tab.ofloxacin
20mg-po-bd * 10 days
Tab.methylcobalamin
500mcg-po-od * 10 days
Syp.disodium hydrogen citrate – 2tbsp in a glass of
water –po-tid
Tab.rantidine
300mg-po-od * 7 days
Follow up advice :
Review after 1 week