A female patient age 26 years admitted in bashaweshwar hospital gulbarga

1. CASE PRESENTATION
BY
RAHMAN KHAN

2. DEMOGRAPHIC DETAILS
• NAME : xyz
• AGE : 26 years GENDER :Female
• DOA : 5/11/2016 DOD : 12/11/2016
• DEPARTMENT : GEN MEDICINE
• I.P NO - 527874
• UNIT : A WARD: MICU

3. SUBJECTIVE EVIDENCE• PRESENT COMPLAIN : c/o yellowish discoloration of skin & nail since 7 days.
• c/o yellowish urine since 3 days & cough since 4 days
• c/o decreased appetite since 1 week.
• HISTORY OF PRESENT ILLNESS : pt. was apparently normal 15 days back then she
developed fever since 4 days which is of low grade continuously present throughout the day
associated with cold & cough insidious onset , non progressive on taking medicine.
• PAST HISTORY : No h/o TB/ASTHMA/EPILEPSY.
• FAMILY HISTORY: nothing significant.
• PERSONAL HISTORY :
• Diet : mixed
• Sleep : normal
• Appetite : decreased
• Bowel & bladder : regular

4. OBJECTIVE EVIDENCE
PHYSICAL EXAMINATIN:
B.P: 110/70 mmHg
PULSE: 78/min
B.TEM: normal
GENERAL EXAMINATION: pt. is conscious and cooperative.
Skin: yellowish discoloration
SYSTEMIC EXAMINATION:
CVS : S1 S2 +ve
Respiratory system : B/L NVBS
Abdominal examination : soft non tender, no organomegaly
CNS : Conscious oriented.
PROVISIONAL DIAGNOSIS: JAUNDICE

5. INVESTIGATION
HAEMOLYTIC EVALUTION:
• HEMOGLOBIN : (13.8-18 gm/dl)-12g/dl
• ESR : (F-0-30mm/hr)- 60 mm/hr
• NEUTROPHIL:(60-70%)- 85%
• LYMPHOCYTE: (22-30)- 25%
• PROTHROMBIN TIME: (11-14sec)- 19 sec
URINE & LFT TEST:
• EPI CELL: 2-3
• PUS CELL: 3-4
• BILE: (0.1-1.0mg/dL) – 9.5mg/dL
• Sr BILE: (upto 0.4mg/dL)- 4.4mg/dL
FINAL DIAGNOSIS: JAUNDICE

6. TREATMENT
drugs Day 1 2 3 4
Inj. CEFITRIAXONE I g I.V √ √ √ √
Ivf DNS RL 10 √ √ √ √
Tab. PARACETAMOL 500mg SOS √ √ √ √
Inj. ONDANSETRON 1amp I.V √ √ √ √
Inj. RABEPRAZOLE 20mg I.M √ √ √ √
INJ URSODESOXY CHOLIC
ACID 1amp I.M
√ √ √ √
Inj.VITAMIN K supp 1 amp √ √ √ √
Syp. AMBROXYL HCL+
SALBUTAMOL
SULPHATE+GUAIPHENESIM
MENTHOL 5ML
√ √ √ √

7. ASSESSMENT OF THERAPY
• INJ CEFTRIAXONE 1g I.V
MOA : it is third generation cephalosporin which are selectively inhibits bacterial cell wall synthesis by
binding to trans peptidases which are penicillin-binding proteins.
SIDE EFFECTS: chest pain,chill,cough,fever,painful urination
• IVF DNS RL (DEXTROSE)
it provide calories and are source of water for hydration.
SIDE EFFECTS: itching, rashes, swelling of the mouth face lips
• TAB PARACETAMOL 500mg
MOA:NSAID’s ANALGESIC
SIDE EFFECTS: skin rashes, itching, diarrhoea, nausea, vomiting
• INJ ONDANSETRON
MOA- It is given to reduce vomiting by blocking emetogenic impulses in the gut and their central rely.
SIDE EFFECTS: confusion, dizziness, fever, headache, weakness
• INJ RABEPRAZOLE
MOA: proton pump inhibitor.it suppresses gastric acid secretion by specific inhibition of hydrogen-
potassium adenosine triphosphates.
SIDE EFFECTS: dark urine, dry mouth, fever, chills, nausea, vomiting.

8. • INJ URSODESOXYCHOLIC ACID
MOA: these drug reduce cholesterol absorption and also relieve itching in intrahepatic cholestasis.
SIDE EFFECT: constipation, headache, back pain, dizziness etc..
• INJ VIT K
MOA- It helps to treat and prevent unusual bleeding by increasing the body’s production of blood clotting
factors.
SIDE EFFECTS: decreased. appetite, difficulty in breathing, enlarge liver etc.
• SYPAMBROXYL HCL+SALBUTAMOL SUPHATE+GUIPHENESIM MENTHOL (EXPECTORANT)
MOA:TERBUTALINE is selective beta2 adrenergic agonist which stimulate beta 2 receptor thus producing
relaxation of bronchial smooth muscle.
AMBROXOL: it promotes the removal of tenacious secretion in the respiratory tract and reduce mucous.

9. DRUG INTRACTION
• No drug interaction were found in these medication.
DISCHARGE MEDICATION:
• Tab. PARACETAMOL 500mg SOS
• Tab ONDANSETRON
• Tab `RABEPRAZOLE 20mg
• Tab URSODESOXY CHOLIC ACID
• Tab VITAMIN K
• Syp. AMBROXYL HCL+ SALBUTAMOL SULPHATE+GUAIPHENESIM MENTHOL 5ML

10. PLANNING
COMMUNICATION WITH THE PATIENT
Medication should be followed regularly .
Proper dose should be taken
Proper diet should be done.
Avoid oily and spicy foods.