A 35 year old male patient was presented with
complaints of fever since 2 days, pain in the abdomen which
was sudden in onset and gradually progressing since 5 days and
relieved on medication. H/O two episodes of vomiting. He had
no history of recent bleeding, fever, or heart disease. He had not
been exposed to medications or toxins.
He is a chronic smoker and alcoholic, and had no previous
hospitalizations.
He works as Cooli and is on mixed diet but has anorexia. His
sleep, bowel and bladder habits are normal.
Findings on the physical examination were unremarkable except
for mild tachycardia at rest (100 bpm), a blood pressure of 120/70
mm Hg, 18cycles/min and 101o F. Abdomen shows diffuse
tenderness, Normal S1&S2 sounds,
Bilateral air entry and
normal vestibular breath sounds, and no focal neuronal deficit.
The results of Laboratory investigations were Hb: 9gm/dl, WBC:
13,000cells/mm3, Serum amylase: 200U/L, Serum lipase: 300U/L
Pus cells: 15-20cells/µl of urine, CECT Abdomen: Acute
pancreatitis with minimal peripancreatic inflammatory changes.
ECG: Tachycardia, based on these results he was hospitalised.
1. Acute Pancreatitis
2. Urinary tract infection
ACUTE PANCREATITIS:
Abdominal pain which was sudden in onset and gradually
progressing since 5 days
Fever
Two episodes of vomiting.
Anorexia
Tachycardia
Anemia
WBC: 13,000cells/mm3
Serum amylase: 200U/L,
Serum Lipase: 300U/L
Bilirubin: 2mg/dl
CECT: Acute pancreatitis with minimal peripancreatic
inflammatory changes.
ECG: Tachycardia
Current Medications:
Tab. Dolo 650mg, TID Inj. Pantop 40mg, OD, IV Inj. Tramadol in 100ml NS TID Tab. Ultracet TID IV Fluids NS/DNS@75ml/hr
ASSESSMENT:
Etiology:
Alcoholism
Risk factors:
Alcohol
Day 7-9
Day 7-12
Day 7th
Day 8-12th
Day 7-12
ACUTE PANCREATITIS:
Yes patient needs therapy to
1. Alleviate symptoms and prevent further complications
like necrosis, Acute pseudo-cyst, pancreatic abscess,
acute cholicystitis, pancreatic ascites, obstructive
jaundice, pneumonitis, ARDS, portal vein thrombosis,
erosive gastritis
2. Eradicate the cause.
3. To reduce the pain and inflammation.
4. To improve clinical symptoms
PLANNING
RECOMMEND DRUG TREATMENT( DRUGS TO BE
AVOIDED; FURTHER TESTS)
ACUTE PANCREATITIS:
Aggressive volume repletion, pain control,
close
monitoring of hemodynamic and volume status, attention
to nutritional needs, and monitoring for complications are
essential in patients with acute pancreatitis.
Infection of necrosis is the most serious local complication
of acute pancreatitis. So it can be prevented by
administration of prophylactic antibiotics like
Imipenem - 500 mg IV every 8 hours for 10-14days
Alternatives:
cefuroxime (1.5 g IV every 8 hours), for 10days
Drugs To be avoided:
Avoid drugs like Azathioprine
6-mercaptopurine
Sulfonamides
Estrogen
Tetracycline
Valproic acid
Hydrochlorothiazide
Corticosteroids
Furosemide, erythromycin
Carbamazepine
Goals :
1. Eradicate the cause
2. Normalize biochemical markers
3. Prevent progression to necrosis, pancreatic ascites,
obstructive jaundice, pneumonitis, ARDS, portal vein
thrombosis, erosive gastritis
4. Improve clinical symptoms
Monitoring parameters:
1. WBC
2. Bilirubin
3. Serum amylase and lipase
4. Liver enzymes
Side effects of Tramadol:
Side effects of Ultracet:
 Sweating
 Dizziness
 Nausea
 Vomiting
 Dry mouth
 Fatigue
 Asthenia
 Somnolence
 Confusion
 Constipation
 Flushing
 Headache
 Nausea, vomiting
 Constipation
 Diarrhoea
 Abdominal pain
 Dry mouth
 Dyspepsia
 Flatulence
Side effects for Pantop:
 Diarrhoea
 Dizziness
 Pruritus
 Skin rashes
 GI tract infections
URINARY TRACT INFECTION
Fever
WBC: 13,000cells/mm3
Pus cells: 15-20 cells/µl of urine
Current Medications:
Tab. Dolo 650mg, TID
ASSESSMENT:
Etiology:
Unhygienic habits
Risk factors:
1. Urinary tract obstruction
Day 7-9
UTI:
Yes patient needs therapy to
1. Alleviate symptoms and prevent further
complications like kidney failure,
Acute Nephrotic Syndrome,
Chronic Urinary Tract Infections,
Congestive heart failure.
2. Eliminate the cause.
3. To improve clinical symptoms
PLANNING
RECOMMEND DRUG TREATMENT( DRUGS
TO BE AVOIDED; FURTHER TESTS)
UTI:
Nitrofurantoin – 100mg PO bid for 5-7 days
• It Should be taken with food. Take with or
immediately after meals
Fosfomycin 3gm single dose sachet
• Take on an empty stomach 1 hr before or 2 hr after
meals
Pivmecillinam 400mg, PO, bid for 3-7days
• Take Pivmecillinam with meals
Goals:
1. Eradicate the cause
2. Normalize biochemical markers
3. Relive symptoms
4. Prevent progression to Kidney failure,
Acute Nephrotic Syndrome,
Chronic urinary tract infections
Congestive heart failure.
Monitoring parameters:
1. Pus cells
Side effects of
Nitrofurantoin:
 Headache
 Fever
 Pharyngitis
 Photophobia
 Nausea
 Diarrhoea
 Constipation,
 Headache
Side effects of Fosfomycin:
 GI disturbances
 Headache
 Tremor
 Confusion
 Convulsions
 Rashes
 Joint pain
 Phototoxicity
About medications:
Tab: Ultracet:
May be taken with or without food.
Tab. Paracetamol:
Take Paracetamol before or after food.
You can take a dose of Paracetamol every 4-6 hours if
needed, but do not take more than four doses in any 24hour period.
Patient Counseling Tips
1. Stop drinking alcohol
2. Quit smoking
3. Limit the amount of caffeine, spicy and gas-forming foods
that you eat.
4. Drinking plenty of water and fluids like cranberry juice
which will help in removing the pus cells out of the urinary
tract.
5. Avoid resisting the urge to urinate. Holding the urine for
long time keeps the harmful bacteria inside the bladder.
6. Bacteria that affect the urinary system pass through stools.
So, clean the anus from front to back after defecating
7. Practice good hygiene
Type of
problem
Needs
additional drug
therapy
Possible Cause
Comment
Untreated
condition
Nitrofurantoin – 100mg PO bid for
5-7 days
Needs
additional drug
therapy
Untreated
condition
Prochlorperazine at a dose of 5 to
10 mg IV q 6 hourly
Needs
additional drug
therapy
Untreated
condition
One tablet of iron bis-glycinate
(Ferrochel, Gentle Iron) contains 27
mg of elemental iron, three times
daily can increase the Hb level
significantly.
1. Drug therapy problem: Prophylactic Therapy
Therapy goals/ Therapy end points: To Prevent necrosis
Therapy recommendations: Imipenem (500 mg IV every
8 hours for 10-14days )
2. Drug therapy problem: Untreated condition
Therapy goals/Therapy end points: To treat Urinary
tract infections
Therapy recommendations: Nitrofurantoin – 100mg PO
bid for 5-7 days
3. Drug therapy problem: Untreated condition
Therapy goals/Therapy end points: To treat Vomiting's
Therapy recommendations: Prochlorperazine at a dose of 5
to 10 mg IV q 6 hourly
4. Drug therapy problem: Untreated condition
Therapy goals/Therapy end points: To Increase hemoglobin
levels
Therapy recommendations: One tablet of iron bis-glycinate
(Ferrochel, Gentle Iron) contains 27 mg of elemental iron,
three times daily can increase the Hb level significantly. A
250 mg of ascorbic acid tablet or a half-glass of orange juice
is given at the time of iron administration to enhance the
degree of iron absorption. Iron should be given two hours
before, or four hours after, ingestion of antacids.
Harrison principle of Internal Medicine Vol:2, Pg. no:
2634-2643
Pharmacotherapy, A pathophysiologic approach by
Joseph. T. Dipiro, Pg:no: 659-675
http://www.merckmanuals.com/professional/gastrointesti
nal_disorders/pancreatitis/acute_pancreatitis.html
http://www.clevelandclinicmeded.com/medicalpubs/disea
semanagement/gastroenterology/acute-pancreatitis/
http://www.gihealth.com/html/education/pancreatitis.html
http://www.acep.org/Content.aspx?id=65139
http://umm.edu/health/medical/reports/articles/urinarytract-infection
http://www.med.umich.edu/1info/fhp/practiceguides/uti/u
ti.pdf
http://pubs.niaaa.nih.gov/publications/arh21-1/13.pdf