case 2 Acute calculus Cholecystitis dm sri.docx

#medical#case

1. CASE STUDY ON TYPE 2 DIABETES MELLITUS, ACUTE
CALCULUS CHOLECYSTITIS
SOAP NOTE
SUBJECTIVE:
•A 69 years old Male patient was admitted on Surgical Gastroenterology
department on 18/6/23 presented with the chief complaints of Upper
abdominal pain since last night. H/O vomiting (2 episodes), fever.
•Past medical history: diabetic mellitus 3 years ,SHTN 2yrs but not on Rx
•Past medication history: Metformin 500mg 1-0-0
•Surgical history: Nil
OBJECTIVE:
GENERAL EXAMINATION : Conscious ,oriented ,afebrile
PARAMETER SUBJECT VALUE NORMAL VALUE INFERENCE
TEMPERATURE 98.6
0
F 98.6
0
F →
BP 170/100 mmHg 120/80mmHg ↑
RR 16breaths/min 16-20 breaths/min →
Spo2 98% 95-99 % →
PR 92 beats/min 60-100 b/min →
CBG 158mg/dl 70-130 mg/dl ↑
SYSTEMIC EXAMINATION:
CVS:S1S2+,No murmur.
RS:B/LAE+,No added sound
PA: Soft,Tenderness+ upper abdomen in epigastric region+
CNS:NFND
LABORATORY DATA :
HAEMATOLOGY
PARAMETERS SUBJECT VALUE NORMAL LEVEL INFERENCE
Hemoglobin 15.3 13-17g/dl →
PCV 47.1 35.5-44.9% ↑
MCV 91.1 80-100 fl →

2. MCH 29.5 27-32 pg →
White Blood Cells10500 4500-11000cells/
mm3
→
Platelet count 210000 150000-
450000cells/mm3
→
Neutrophil 70.7 45-75% →
Lymphocyte 18.1 20-40% 
Esonophil 3.7 0-6% →
Basophil 0.1 0-2% →
Monocyte 7.4 2-8% →
Urea 32 6-20mg/dl ↑
Creatinine 0.7 0.7-1.3mg/dl →
Uric acid 4.8 4.5-8.0 mg/dl →
SGOT 24 <40IU/L →
SGPT 22 <50IU/L →
T.Bilirubin 0.5 0.2-1.2mg/dl →
D.Bilirubin 0.2 0-0.4mg/dl →
IN.Billirubin 0.3 0-0.4mg/dl →
Albumin 3.5 3.5-5.5g/dl →
Globulin 1.9 2.0-3.5g/dl 
T.Protein 54 6-8g/dl ↑
Na 135 136-145mEq/L →
K 3.7 3.5-5.1mEq/L →
Cl 98 96-106mEq/L →
Ca 9.0 8.6-10mg/dl →
Bt 2mins 2-7mins →
Ct 4mins 5-15mins 
OTHERS:
CT Abdomen: Gall bladder distended multiple calculi largest 12 x 10 mm calculus
(16 x 8mm at neck).
Surgical Plan: Removal of gall bladder and stone by laproscopic cholecystectomy.
ASSESSMENT:
PROBLEM 1: ACUTE CALCULUS CHOLECYSTITIS
PROBLEM 2:TYPE 2 DIABETES MELLITUS
THERAPEUTIC PLAN:

3. S.NO BRAND NAME GENERIC
NAME
DOSE FREQ ROUTE DURATION
1.INJ.TRAMADOL Tramadol 100mg 1-0-1 IV D1-D2
2.INJ.FENTANYL Fentanyl 150mg STAT IV D1-D2
3.INJ.PAN Pantoprazole40mg 1-0-1 IV D1-D2
4.INJ.EMESET Ondansetron 4mg 1-0-1 IV D1-D2
5.INJ.PARA Acetaminophen 1g 1-1-1 IV D1-D2
6.INJ AVIL Pheniramine 25mg STAT IV D1-D2
7.INJ MAGNEX
FORTE
Cefoperazone,
Sulbactam
1.5g 1-0-0 IV D1-D2
8.T. METFORMIN Metformin 500mg 1-0-0 P/O D1-D2
PROGRESS CHART:
DAYS PROGRESS DRUGS
Day 1Patient comes with C/O Abdominal pain+ ,pain score:3/10
O/E: Concious,oriented,afebrile
O/E:BP-120/80mmHg,PR-80Beats/min,SPO2-98%,CBG-
110mg/dl
Surgery done: Laparoscopic cholecystectomy was done
Mild pain at surgical site,Pain score-1/10
INJ.PARACIP ,
INJ.PAN,
INJ.TAXIM,
INJ.TRAMADOL
Day 2Tolerating oral liquid diet,No freash complain seen . patient is
stable and plan for discharge. O/E:BP-120/80mmHg
INJ.PARA
BRAND NAME CATEGOR INDICATIDOSE FREQ STD. STD. RATIO

4. Y ON DOSE FREQ NALIT
Y
INJ.TRAMADOL Opioid
Analgesics
It is used to
treat
moderate to
severe pain
100mg 1-0-1100mg 1-0-1 Yes
INJ.FENTANYL Narcotic
(opiate)
analgesics.
To treat
chronic
pain
150mgSTAT 150mg STAT Yes
INJ.PAN Proton pump
inhibitor
To treat
Acid reflux
40mg 1-0-140mg 1-0-1 Yes
INJ.EMESET Anti-EmeticsTo prevent
Nausea and
vomiting
4mg 1-0-14mg 1-0-1 Yes
INJ.PARACIP Analgesics&
Antipyretics
To relieve
pain and
reduce
fever
1g STAT 1g STAT Yes
INJ AVIL Anti-
histamine
To
treat allergi
c
conditions
25mg STAT 25mg STAT Yes
INJ MAGNEX
FORTE
AntibioticsTo treat
bacterial
infection
1.5mg 1-0-01.5mg 1-0-1 Yes
T METFORMIN Oral anti-
diabetic drug
To treat
high blood
sugar levels
500mg 1-0-0500mg 1-1-1 Yes
CRITICAL ANALYSIS:
PLAN:
GOALS OF THERAPY:
The goal of Cholecystitis include relieving pain and promoting rest,
Maintaining fluid and Electrolyte balance
To reduce morbidity and to prevent Complications.
DRUG-DRUG INTERACTION:

5. INTERACTION SEVERITY RESULTANT EFFECT
FENTANYL+ TRAMADOL Serious It can lead to serious side effects
seizure, respiratory disstress
Pharmacodynamic antagonism.Pa
tient should be observed closely
for hypoglycemia.
DRUG-FOOD INTERACTION: NIL
PHARMACIST INTERVENTION:
The Prescription was found to be Rational.
HbA1C is not performed ,it is the main parameter for T2DM.
LFT should be done again to know the progress of therapy.
PATIENT COUNSELLING:
REGARDING DISEASE S:
ACUTE CALCULUS CHOLECYSTITIS :Calculus cholecystitis develops when the
main opening to the gallbladder ,the cystic duct get blocked by a gallstone.
TYPE 2 DIABETES MELLITUS:This condition is a disease that occurs when your
blood glucose, also called blood sugar, is too high. Blood glucose is your main source of
energy and comes mainly from the food you eat. Insulin, a hormone made by the
pancreas, helps glucose get into your cells to be used for energy.
REGARDING DRUGS:
DRUGS DOSE FREQ DIRECTIONS
T.CEFIXIME 200mg 1-0-1It is used to treat Bacterial infection.It should be
taken 30 min after food at morning and evening
for 4 days.
T.ZERODOL-P 100/325mg 1-0-1 It is used to treat Pain and Inflammation.It
should be taken 30 min After food at morning
and evening for 4 days.
T.PANTOPRAZOLE 40mg 1-0-1It helps to reduce the amount of Acid production
in your stomach.It should be taken 1 hour before
food at morning for 4 days.
SYP.LACTIHEP 15ml 1-0-1 It is used to treat constipation,measure 15 ml

6. with measuring cup and it should be taken 30
min after food at morning and evening for 4
days
REGARDING LIFESTYLE MODIFICATIONS:
 Eat healthy fats like fish oil and olive oil, to help your gall bladder contract
and empty on a regular basis.
 Avoid unhealthy fats like fried foods.
 Eat fewer refined carbohydrates& less sugar.
 Eat more foods that are high in fiber such as beans & peas, whole grains
including Brown rice
 lot of essential fatty acids to support the transportation of cholesterol and to
stimulate the production and secretion of bile. Essential fatty acids are found
in natural, cold-pressed oils, such as flax seed oil and olive oil. 
Reduce your intake of saturated fats (from meat and dairy products). 
Favour high-fiber foods, especially water-soluble fibers (e.g. apple, carrots,
oat bran and dried beans) that help bind and eliminate cholesterol and harmful
agents.
A minimum of 8 glasses of water (250 ml) per day to allow the fibers to
function properly. 
Maintain a healthy weight