DEPARTMENT OF PHARMACOLOGY

VCSGGMSRI,Srikot, Garhwal
Uttrakhand
CLINICAL CASE SHEET
PRESENTATION

BY SHREYA DIMRI
BATCH 2016
ROLL NO.-87
DEPARTMENT OF PHARMACOLOGY
VCSGGMS&RI, SRIKOT,GARHWAL,UTTARAKHAND

CLINICAL CASE SHEET

NAME OF PATIENT : Smt Maheshwari REGN N0. : 85717

AGE: 32 yrs SEX : Female DEPARTMENT : Surgery

WEIGHT : 54 kg ADDRESS : Rudraprayag

CHIEF COMPLAINTS : The patient came to the hospital with the following

chief complaints on 26/09/2018 at 10:24 a.m. :-

1) Rt. Flank pain.

HISTORY OF PRESENT ILLNESS

The person was apparently asymptomatic when

she first experienced pain on the right side of
body and nausea 1 week back.

 Pain
 Sharp and sudden in onset.
 Duration- 7-8 days
 Continuous in nature
 Associated symptoms- nausea, vomiting,
burning and frequent micturition.
 PastMedical History-
No any past medical history.

 PastSurgical History-
No past surgical history.

 Negative History:
 No history of pain abdomen.
 No history of Hypertension, DM, TB.

 Personal History
 Diet- mixed diet
 Bowel and bladder habits – normal
 Sleep- normal patterns.
 No history of smoking and alcohol addiction.
INVESTIGATIONS

HAEMATOLOGY

Hb : 14.3gm/dL

TLC
SEROLOGY
: 7200/cmm
 HBsAG-Negative
DLC :
Polymorphs- 92%  HIV I and II-Negative
o Lymphocytes- 30%
o Monocytes - 3% 
o Eosinophils- 0% HCV-Negative
Platelet Count : 3.90 lakh/uL
PCV: 36.3%

BIOCHEMISTRY

 RENAL FUNCTION PROFILE –

Blood Urea : 36 mg/dL
Serum Creatinine : 0.8 mg/dL

 LIVER FUNCTION PROFILE – PROVISIONAL DIAGNOSIS: UROLITHIASIS

serum bilirubin(total) : 0.5mg/dL
SGPT – 20U/L
SGOT – 26U/L
serum ALP - 46
STANDARD TREATMENT FOR UROLITHIASIS
DRUG DOSE MOA REMARKS
DICLOFENAC 75mg inj. IM Inhibits PG synthesis and is COX Provides relief from renal colic.
2 selective
TAMSULOSIN 0.4 mg OD orally It is a alpha 1 adrenergic blocking By it’s relaxant effect helps in easy
agent and causes relaxation in the passage of renal stones.
bladder .

HYDROCHLORTHIAZIDE 25mg BD orally A thiazide diuretic that inhibit Na Cl Used to treat specifically calcium
symport at DT stones in kidney

ALLOPURINOL 200 mg OD orally It competitively inhibits xanthine Used in treatment of stones majorally
oxidase and reduces uric acid consisting of uric acid
synthesis

ACETOHYDROXAMIC ACID 10-15mg/kg OD orally Irreversible enzyme inhibitor of the Used with antibiotics to treat bladder
urease enzyme in various bacteria’s infections. Decreased ammonia
prevents stone formation.

PIPERACILLIN 6-8g iv OD A beta lactam antibiotic of Used before surgeries to prevent

ureidopenicillin class that interferes bacterial infections
with bacterial cell wall especially
gram –ve bacteria.

POTASSIUM CITRATE 10 mEq TDS orally A urine alkalizing agent that Prevents uric acid and cystine kidney
crystallizes stone forming salts such stones from forming.
as calcium oxalate,etc within the
bladder.
 PRESCRIBED MEDICINES

S.NO DOSAGE DRUGS DOSE DURATION & ROUTE

FORM DOSE
INTERVAL

1. Inj. Monal 4.5gm TD i.v

2. Inj. Amikacin 750mg OD i.v

3. Inj. Pantop 40mg OD i.v

4. Inj. Diclo 75mg TDS i.v
5. Inj. Ticmol 1gm TDS i.v

6. Syp. Renalka 2 tsf BD oral

7. Inj. RL soln. 2 Stat iv.

Q1. Is the name of drug written legibly?

1 2 3 4 5 6 7
Q9. Is antibiotic prescribed or not? If yes, then name them.
Y Y Y Y Y Y Y
Yes ,
Q2. Is the strength written or not?

1 2 3 4 5 6 7
inj.MONAL(PIPERACILLIN+TAZOBACTAM),AMIKACIN
N N N N N N N

Q3. Is the dose of prescribed medication written?

1 2 3 4 5 6 7
Q10. Is patient suffering from any adverse drug reaction?
Y Y YY Y Y Y
NO
Q4. Is the dosage form mentioned?

1 2 3 4 5 6 7
Y Y Y Y Y Y Y Q11. Total number of drugs prescribed?
Q5. Is the frequency of drug mentioned?
7
1 2 3 4 5 6 7
Y Y Y Y Y Y Y

Q6. Is the route of administration mentioned?

Q12. Medicines used by generic and brand name :-
1 2 3 4 5 6 7
Y Y Y Y Y Y Y

Q7. Is the abbreviation used?

Medicines used by generic name: 4
1 2 3 4 5 6 7
N N Y Y N N Y 1.Amikacin 2.pantop( pantoprazole)
Q8. Are all the drugs administered on time?
1 2 3 4 5 6 7
3.Diclo( diclofenac) 4.Ringer Lactate
Y Y Y Y Y Y Y
.
NO

Medicines used by brand name: 2

1. Monal (piperacillin ,tazobactam)
2.TICMOL
3.Renalka

Q13. Any ayurvedic/homeopathic medicine used? Yes

1.syrup Renalka
 CONCLUSION

Pros:

Drug name is written legibly.

Route, frequency and dosage form of all prescribed drugs are written.

Cons:

Strength of all prescribed drugs are not written.

Drug combination if used: inj. Monal( piperacillin+ tazobactam)

RATIONALITY OF PRESCRIBED MEDICINES

1.Monal( piperacillin , tazobactam)-

Piperacillin is a ureidopenicillin active against gram negative bacteria. Tazobactam
is a beta lactamase inhibitor. Inj monal is used for intra abdominal ,kidney and
urinary tract infections. It’s use here is RATIONAL.

2.Pantop( pantoprazole)-
pantoprazole is a proton pump inhibitor used to reduce acid secretion and provide
relief in gastic and duodenal ulcers and GERD’s. It’s use here is IRR ATIONAL.

3. Diclo( diclofenac)-
A analgesic, antipyretic and anti inflammatory drug. It is used to relieve renal
colic.It’s use here is RATIONAL since the patient complains of pain.
4. Renalka-
Renalka is a syrup whose anti inflammatory and analgesic properties soothe the inflamed mucosa and alleviate
the burning sensation or pain that occurs during urination. It’s use is RATIONAL here because the patient
suffered from burning micturition.

5. Amikacin-
Amikacin is a broad spectrum aminoglycoside antibiotic mostly used against gram negative bacteria. Emperically
it is used for the treatment of hospital acquired G-ve bacillary infection.Hence it’s use is IRRATIONAL here.

6. Ringer Lactate solution-

It is used to replenish body fluids and maintain electrolyte balance in body.It is also used to compensate blood
loss caused due to trauma and surgery. It’s use is RATIONAL

7.Ticmol (paracetamol) -
it is commonly used for it’s antipyretic and analgesic effects. It is used in headache, musculoskeleton pain,
migraine etc. However its use is IRRATIONAL here.
FINAL REMARKS ABOUT RATIONALITY

 Monal , Diclo, Renalka and Ringer lacatate are rational.

 Pantop, Amikacin and Ticmol are irrational.

THANK YOU …