this case is on Sepsis, that i have taken in SMIH hospital dehradun, India

1. CASE PRESENTATION ON
SEPSIS
Presented By-
Shahnawaz Ahmad Teli
M.Pharm 2st Sem.
(Clinical Pharmacy)

2. Case presentation

3. PATIENT DETAILS
 Patient ID:17350/17
 Patient name: XYZ
 Age: 74 years
 Gender: Female
 Weight: 145.5 kg
 Height: 5'2''
 Date of admission: 15/03/2107
 Date of discharge: 18/03/2017

4. REASON FOR ADMISSION
 The patient’s primary caregiver reports that the
patient has been vomiting a lot in the last few days.
•Past Medical History- Asthma, HTN, OA, Morbid obesity,
Depression
•Past surgical history- ventral hernia 3 months ago
Cholecystectomy (unknown time frame)
•Past Medication History - Nil
•Family history: No HTN, DM, CA, or vascular disease

5. Social history-
 One to two cigarettes every other day; stopped in the
last year.
 Also stopped drinking alcohol in the last year.

6. PHYSICAL EXAMINATION:-
 General condition -- Morbidly obese, white female in
moderate distress
 CNS -- Conscious
 CVS -- Tachycardia, regular rhythm; NL S1/S2
 Chest -- Positive for expiratory wheezes throughout;
tachypnea
 P/A -- + pannus, unable to palpate organs, tenderness to
deep palpation

7. VITAL SIGHS
 BP - 87/43 mmHg
 PR- 80-95/min.
 RR - 14–33/min.
 Temp.- 37.8°C
 SpO2 - 94%

8. LABORATORY DATA-
Investigation Normal Values
Sodium (serum) 133 137 – 145 mmol/l
WBC 25000 4000-11000 c/mm3
AST 11 14 – 36 U/l
ALT 7 14 – 36 U/l
T. bilirubin 0.2 0.3-1.0 mg/dl
Albumin 2.1 3.5 – 5 g/dl
Alkaline phoshatase 127 30-120 IU/L
Haemoglobin 13.6 12-15 g/dl

9. LABORATORY DATA-
Serum Creatinine 1.1 0.8- 1.5 mg/dl
BUN 13 7-20 mg/dL
Cl 98 96-106 mEq/L

10. OTHER INVESTIGATIONS-
 ECG:- sinus tachycardia (113)

11. ASSESSMENT:-
 74-year-old female in septic shock with acute
respiratory and renal failure; probable intra-
abdominal infection.

12. GOALS OF TREATMENT
 Start adequate antibiotic therapy (proper dosage and
spectrum) as early as possible.
 Resuscitate the patient, using supportive measures to
correct hypoxia, hypotension and impaired tissue
oxygenation.
 Identify the source of infection, and treat with
antimicrobial therapy, surgery or both.
 Maintain adequate organ system function.

13. MEDICATION CHART
Name, strength, route, frequency
Date
started
Date
stopped Class
Inj. Norepinephrine 20 mcg/min 15/3/17 Till disch. Vasopressor
agent
Inj. Vasopressin 0.04 units/min 15/3/17 18/3/17 Hormone
Inj. Levofloxacin 500 mg IV daily 15/3/17 Till disch. Second gen.
Fluoroquinolone
Tab. Theophylline ER 400 mg Q AM 16/3/17 18/3/17 Bronchodilator
Fluticasone inhaler 2 puffs BID 16/3/17 till disch. Synthetic
Glucocorticoid
Tb. acetaminophen 100 mg po Q 6
h
15/3/17 till disch. Analgesic
Tab. Mirtazapine 15 mg po at
bedtime
16/3/17 till disch. Antidepressant
Tab.Promethazine 25 mg po Q 6 h 16/3/17 til disch. Antiemetic

14. CLINICAL JUSTIFICATION
 The treatment was almost satisfactory.
 There was a need of extra fluids to help keep
the blood pressure from dropping dangerously
low, throwing the patient into shock.
 Mirtazapine was given, but there was no any
depression.

15. DISCHARGE SUMMARY-
 Tb. acetaminophen 100 mg po Q 6 h X 10 days
 Tab. Mirtazapine 15 mg po at bedtime X 5 days
 Tab.Promethazine 25 mg po Q 6 h X 5 days
 Tab . Levofloxacin 500 mg BD X 10 days

16. PATIENT COUNSELLING
 Avoid smoking and second hand smoke.
 Maintain hygienic conditions.

17. Thank You