CASE PRESENTATION ON EPIGASTRIC

DISCOMFORT

SUBMITTED BY:
B. SWATHI
336115820008
PHARM-D IInd year
 PATIENT DETAILS:

Name : XXX
Age : 46 yrs
Gender : male
Weight : 73 Kgs
Height : 5.3
IP no : 526897
Dept : General medicine
DOA : 14/11/2016
Consultant : Dr.Venkateshwarulu M.B.B.S , M.D
CHIEF COMPLAINTS:
Patient was alright 2 days back and he developed pain in the abdomen
as he took alcohol with empty stomach at late night and 2 episodes of
vomiting in the next day morning .
Tighten in chest region.
PAST MEDICAL HISTORY:

No past medical history.

 PHYSICAL EXAMINATION:
PARAMETERS NORMAL RANGE REPORTED VALUES
BLOOD PRESSURE 120/80 mmHg 130/90 mmHg
PULSE RATE 84 bpm 68 bpm
TEMPARATURE 98.4 F 98.4F

COMPLETE BLOOD PICTURE:

PARAMETERS NORMAL VALUE REPORTED VALUE
HAEMOGLOBIN 14-18g/dl 18g/dl
RBC COUNT 4.4-5.7 cells/cumm 5.8 cumm/cells
WBC COUNT 4,000-11,000cells/cumm 15,500cells/cumm
LYMPHOCYTES 16-46% 10%
MONOCYTES 4-11% 2%
ESINOPHILS 0-8% 3%
BASOPHILS 0-3% 00%
ESR <6mm/hr 8mm/hr
ELECTROLYTES:
PARAMETERS NORMAL RANGE REPORTED RANGE
SODIUM 135-153 meq/L 144meq/L
POTASSIUM 3.5-5.0meq/L 4.3meq/L
CHLORIDE 95-105meq/L 122meq/L
CALCIUM 9- 10.5mg/dl 1.09meq/L

RENAL FUNCTION TEST

PARAMETERS NORMAL RANGE REPORTED RANGE

UREA 20-40 mg/dl 22 mg/dl

Serum creatinine 0.7-1.4mg/dl 0.8mg/dl

FINAL DIAGNOSIS:

EPIGASTRIC DISCOMFORT
 DRUG CHART:
DRUG NAME GENERIC NAME CATEGORY DOSE ROUT FRE D-1 D-2
E
INJ.Piptaz Piperacillin Pencillin 4.25 gms IV BD

INJ.Metrogyle Metronidazole Anti protozoal 500mg IV TID

INJ.Perinorm Metoclopramide Antiemitic 2ml IV BD

hcl
INJ.Pantop Pantoprazole Proton pump 40mg IV OD
inhibitor
INJ.Phenargan Promethazine H1antihistamine 25mg IV BD

INJ.Tramadol Tramadol hcl Analgesic 1ml IV BD

PHARMACEUTICAL CARE PLAN :

subjective

Soap
planning annalysi objective

assesmen
t
 SUBJECTIVE EVIDENCE :
Abdominal pain .
2 episodes of vomiting .
chest pain

OBJECTIVE EVIDENCE
The patient has the increased levels of BP , RBC Count , ESR .

she is having the decreased levels of lymphocytes, Monocytes ,

Calcium.

Our prime object Is to optomie these levels .

 ASSESMENT :
From the subjective and objective evidence the given case was diagnosed
as EPIGASTRIC DISCOMFORT .

PLANNING
Inj . Piptaz is a piperacillin is a pencillin antibiotic given to inhibit the
growth of bacteria .
Inj . Metrogyl is a metronidazole is an anti protozoal given to kill the
protozoal bacteria .
Inj . Perinorm is a metoclopramide is an antiemetic given to treat emesis .
Inj . Pantop is a pantoprazole is a proton pump inhibitor which is given to
reduce the gastric acid secretions.
Inj . Phenargan is a promethazine is an antihistamine given to block the
chemical histamine in the body
Inj . Tramadol is a tramadol hcl is an analgesic given to reduce pain .
ADVERSE EFFECTS:

Inj . Piperacillin Bleeding .

Inj . Metronidazole Anorexia , nausea , vomiting , headache , dryness
of mouth , dizziness , abdominal cramps , loose stools , seizures .
Inj . Metoclopramide hcl - restlessness , drowsiness , fatigue ,
gynaecomastia , lassitude .
inj . Pantoprozole headache , diarrhoea , skin rashes , dizziness .
Inj . Trmadol hcl sweating , nausea , vomitting , stupor .
Inj . Promethazine Abdominal pain , headache, dark urine , chills ,
fever , blurred vision , cough .
DRUG DRUG INTERACTIONS :
TRAMADOL METOCLOPRAMIDE (MAJOR)
Tramadol combining with oter medicines can cause seizures and
metachlopromide may increase that risk .

DRUG FOOD
INTERACTIONS:
METOCLOPRAMIDE FOOD (MODERATE)
Alcohol can increase the nervous system side effect of tramadol such as
dizziness , drowsiness . some may experience impairment in thinking and
judgement . Avoid or limit use of alcohol while treatment with tramadol .
TRAMADOL FOOD (MODERATE )
Alcohol can increase the nervous system side effect of tramadol such as
dizziness , drowsiness . Avoid alcohol intake
PATIENT EDUCATION
EAT A VARIETY OF HEALTHY FOOD .
Healthy food includes fruits , vegetables , low grain breads , low fat diary
products , beans , leanmeat , and fish .
Prefer a special diet
certain food cause pain in abdomen such as alcohol or food that are high
in fat
Eat smaller meals and to eat more often than usual
DRINK LIQUIDS AS DIRECTED .
Prefer fresh fruit juices such as apple juice , orange juice , pineapple juice
etc .
dont have drinks that contain alcohol or caffine .
Avoid intake of alcohol , avoid coffee and tea.
dont skip the medication .