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Isoseptic shock.ppt

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Riddhi Pawaskar

The document describes a 67-year-old male patient presenting with dyspnea, constipation, anorexia, abdominal pain and headache. Examination finds the patient semiconscious and oriented with abdominal discomfort and tender abdomen. Laboratory investigations show abnormal renal function, electrolyte imbalance and signs of infection. The patient is diagnosed with septic shock with acute renal failure of unknown etiology. Treatment includes antibiotics, diuretics, bronchodilators and corticosteroids to address infection, fluid overload and organ dysfunction with the goals of improving quality of life and preventing further health complications.

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ISOSEPTIC SHOCK RIDDHI PAWASKAR (Pharm D IVth year)
SUBJECTIVE DATA NAME: QRS AGE: 67 SEX: M Weight: 65 kg Height: 188cms DOA: 21/10/19 � CHIEF COMPLAINTS: i. Dyspnea ii. Constipation iii. Anorexia iv. Abdominal pain v. Headache ISOSEPTIC SHOCK-Riddhi 2
OBJECTIVE DATA � MEDICAL H/O: Herpes-Zoster No h/o DM,HTN � MEDICATION H/O: 3 haemodialysis done ▪ [Redicate Clav]Cefixime (200 mg) + Clavulanic Acid (125 mg) ▪ [Tb Soft Cold] Chlorpheniramine maleate 2 MG +Paracetamol 125 MG +Phenylephrine 5 MG ▪ [Rabepraz] Rabeprazole 10 MG � SOCIAL H/O: Married, Farmer � FAMILY H/O: N/S � PREVIOUS ALLERGIES: N/S ISOSEPTIC SHOCK-Riddhi 3
PHYSICAL EXAMINATION GENERAL: stable VITALS: BP-140/90 Pulse: 130/min SpO2: % RR: /min HEENT: N CVS: N CNS: semiconscious, oriented GIT: discomfort, tender,palpated GU: N EXT: Left ankle area – dry wound ++ ISOSEPTIC SHOCK-Riddhi 4
Lab investigations: CBC D1 D3 D5 Hb(12- 16g/Dl) 12.3 9.9 11.9 RBC(4-5.5 10^12/L) 4.32 27.1 4.10 WBC(4- 10)10^9/L 16.36 24.70 15.91 NEUT (2- 7)10^9/L 15.35 22.17 14.34 LYM(0.8- 4)10^9/L 0.5 0.89 0.69 PLT (100- 450)10^3/uL 37 162 33 ISOSEPTIC SHOCK-Riddhi 5
Lab investigations P.S EXAM ❖ WBC: Neutrophilic leukocytosis ❖ RBC: hypochromic+, microcytic+, anisocytosis+ ❖ PLT: decreased on smear; no evidence of MP SERUM ELECTROLYTES D1 D2 D3 S. Na 114 117 125 S.K 5.7 5.9 5.9 ISOSEPTIC SHOCK-Riddhi 6
Lab investigations Routine Analysis ▪ S.BUN- 69.0mg/dL (5-25mg/dL) ▪ S.Creat- 5.6mg/dL (0.8-1.4mg/dL) ▪ SGPT- 29.4 U/L (upto 40 IU/L) ▪ D.Bil- 1.5 mg/dL(0-0.4mg/dL) ▪ I.Bil- 1.80 mg/dL(0.4-1.3mg/dL) ▪ T.Bil-3.30mg/dL(mg/dL) ▪ ALP- 236.7IU/L (60-170 IU/L) ▪ S.Alb- 2.2g/dL(3.8-5 g/dL) ▪ S.Glob-2.2g/dL(2.3-3.5g/dL) ▪ T.Prot: 4.4g/dL (6-8 g/dL) ▪ Procalcitonin:56.8 ng/ml (0.15- 0.50 ng/Ml) ▪ RBG: 116 mg/dL(60-120 mg/dL) ABG ▪ pH-7.27 ▪ pCO2- 28 mm Hg ▪ pO2- 88 mm Hg ▪ HCO3- 12.9mmol/L ▪ TCO2- 13.8mmol/L ▪ Beb- -12.6mmol/L ▪ BEecf- -14.0mmol/L ISOSEPTIC SHOCK-Riddhi 7
Lab investigations: URINALYSIS � SUGAR: Nil � ALBUMIN: +ve � 80-90 pus cells with 1-2 RBCs USG � Both kidneys enlarged in size with grade II raised cortical echogenicity � ARF � Mild hepatomegaly � Mild splenomegaly ISOSEPTIC SHOCK-Riddhi 8
Lab investigations STRESS TEST � 0.84 kms( 11 mins) � Max HR: 146 bpm � Max BP: 164/90 � Mild ST Depression � Negative for exercise induced cardiac ischemia C-XR � Normal chest radiograph. � No significant findings ISOSEPTIC SHOCK-Riddhi 9
Lab investigations Leptospira � IgM: -ve � IgG: -ve HbsAg & HIV tridot � NEGATIVE ISOSEPTIC SHOCK-Riddhi 10
ASSESSMENT ❖ FINAL DIAGNOSIS: ISOSEPTIC SHOCK WITH ARF ❖ ETIOLOGY: UNKNOWN ❖ GOALS OF THERAPY: I. To increase quality of life II. Prevent comorbidity, mortality & further progression of disorder III. Reduce adverse events of current therapy and optimize therapy ISOSEPTIC SHOCK-Riddhi 11
PAN 40 mg IV OD(D1-D3) ¤ Generic– Pantoprazole ¤ Category- Proton pump inhibitor ¤ MOA–It is a proton pump inhibitor,inhibits H,K ATPase enzyme which secretes HCl in parietel cells of stomach ¤ Indications-Ulcers and reflux oesophagitis,GERD,Zollinger-Ellison syndrome ¤ Contraindication- Hypersensitivity ¤ Side effects- Headache, diarrhea, dizziness ¤ Pregnancy–US FDA pregnancy category Not Assigned:This drug is only recommended for use during pregnancy when there are no alternatives and the benefit outweighs the risk. ¤ Warnings–Prolonged treatment (greater than 24-36 months) may cause vitamin B12 deficiency. ¤ Std. Dose–20-80 mg/day ISOSEPTIC SHOCK-Riddhi 12
EMESET 4mg IV BD(D1-D3) ¤ GENERIC: Ondansetron ¤ CATEGORY- Anti emetic ¤ MOA: Ondansetron is a selective 5-HT3-receptor antagonist which blocks serotonin, both peripherally on vagal nerve terminals and centrally in the chemoreceptor trigger zone ¤ INDICATIONS: CINV, Post operative nausea/vomitting,pregnancy associated nausea,vomitting. Gastric pareisis ¤ CONTRAINDICATIONS: Hypersensitivity, concomitant use with apomorphine ¤ ADVERSE EVENTS: confusion, dizziness, fever, fatigue, gastric pain ¤ PREGNANCY: US FDA pregnancy category: B ¤ STD. DOSE: recommended dose: 0.15 mg/kg IV, with the first dose (infused over 15 minutes) 30 minutes before the start of emetogenic chemotherapy and subsequent doses given 4 and 8 hours after the first dose. -Maximum dose: 16 mg per dose ISOSEPTIC SHOCK-Riddhi 13
INJ DERIPHYLLN 1amp STAT & OD(D1-D3) ¤ GENERIC: Etophylline (84.7mg) + Theophylline( 25.3mg) ¤ CATEGORY- Bronchodilator ¤ MOA: smooth muscle relaxation (ie, bronchodilation) and suppression of the response of the airways to stimuli (ie, non-bronchodilator prophylactic effects). Bronchodilation is mediated by inhibition of two isoenzymes, phosphodiesterase (PDE III and, to a lesser extent, PDE IV) ¤ INDICATIONS: asthma, bronchitis, COPD,bradycardia ¤ CONTRAINDICATIONS: allergy, Hypersensitivity to xanthine derivatives; coronary artery disease (where cardiac stimulation might prove harmful); peptic ulcers; coadministration with ephedrine in children. ¤ ADVERSE EVENTS: acid base imbalance, irregular heartbeat, persistent vomitting,diuresis, ¤ PREGNANCY: US FDA pregnancy category C ¤ STD. DOSE: Initial dose: 200 mg per day given as evenly divided doses every 6 to 8 hours After 3 days, if starting dose was tolerated: 100 mg per day given as evenly divided doses every 6 to 8 hours ISOSEPTIC SHOCK-Riddhi 14
INJ LASIX 10mg IV stat(D1) ¤ GENERIC: FUROSEMIDE ¤ CATEGORY- Diuretic ¤ MOA: Primarily inhibits reabsorption of sodium and chloride in the ascending loop of Henle and proximal and distal renal tubules, interfering with the chloride-binding cotransport system, thus causing its natriuretic effect ¤ INDICATIONS: Management of edema associated with heart failure, cirrhosis of the liver (ie, ascites), or renal disease (including nephrotic syndrome); acute pulmonary edema. ¤ CONTRAINDICATIONS: Hypersensitivity to sulfonamide-derived drugs; complete renal shutdown; hepatic coma and precoma; uncorrected states of electrolyte depletion, hypovolemia, dehydration, hyperbilirubinemiaor hypoten ¤ ADVERSE EVENTS: electrolyte depletion, painful urination, syncope, SIADH ¤ PRECAUTIONS: Furosemide is a potent diuretic which, if given in excessive amounts, can lead to a profound diuresis with water and electrolyte depletion. ¤ PREGNANCY: US FDA pregnancy category C ¤ STD. DOSE: Initial dose: 20 to 40 mg IV (slowly over 1 to 2 minutes) or IM once; may repeat with the same dose or increase by 20 mg no sooner than 2 hours after the previous dose until the desired diuretic effect has been obtained. Maintenance dose: Administer the dose that provided the desired diuretic effect once or twice a day. ISOSEPTIC SHOCK-Riddhi 15
INJ MONTAZ 1g iv BD(D1- D3) ¤ GENERIC: Ceftriaxone(1000mg) + Tazobactam(125mg) ¤ CATEGORY: Bactericidal,Cephalosporin ¤ MOA: Inhibits bacterial cell wall synthesis by binding to one or more of the penicillin- binding proteins (PBPs) ¤ INDICATIONS: Pyelonephritis, noscomical pneumonia, UTI, ¤ CONTRAINDICATIONS: hypersensitivity to ceftolozane/tazobactam, piperacillin/tazobactam, other members of the beta-lactam class ¤ ADVERSE EVENTS: Fever, irregular heartbeat, dizziness, abdominal pain ¤ PREGNANCY: US FDA pregnancy category Not Assigned ¤ STD. DOSE: 1.5 g IV every 8 hours Duration of therapy: 7 days ISOSEPTIC SHOCK-Riddhi 16
INJ BUSCOPAN 1g IV STAT(D1) ¤ GENERIC: Hyoscine Butylbromide, Scopolamine ¤ CATEGORY: Anticholinergic Agent ¤ MOA: blocks the action of acetylcholine at parasympathetic sites in smooth muscle, secretory glands and the CNS; increases cardiac output, dries secretions, antagonizes histamine and serotonin; at usual recommended doses, causes blockade of muscarinic receptors at the cardiac SA-node and is parasympatholytic ¤ INDICATIONS: Motion sickness, treatment of smooth muscle spasm of the genitourinary or GI tract,adjunct to anaesthesia ¤ CONTRAINDICATIONS: Untreated narrow-angle glaucoma; megacolon, prostatic hypertrophy with urinary retention; stenotic lesions or mechanical stenosis of the GI tract; myasthenia gravis; tachycardia, angina, heart failure; paralytic or obstructive ileus; IM administration in patients receiving anticoagulant therapy ¤ ADVERSE EVENTS: drowsiness and xerostomia, dilation of pupils,migraine, cycloplegia ¤ PREGNANCY: US FDA pregnancy category: C ¤ STD. DOSE: IM, IV, SubQ: 10 to 20 mg; maximum: 100 mg/day ISOSEPTIC SHOCK-Riddhi 17
HYDROCORTISONE 100mg 1amp iv STAT(D1) ¤ CATEGORY: Corticosteroid, Systemic ¤ MOA:May depress the formation, release, and activity of endogenous chemical mediators of inflammation (kinins, histamine, liposomal enzymes, prostaglandins) through the induction of phospholipase A2 inhibitory proteins (lipocortins) and sequential inhibition of the release of arachidonic acid. Hydrocortisone has low to intermediate range potency (dosage-form dependent). ¤ INDICATIONS: immune thrombocytopenia, warm autoimmune hemolytic anemia), allergic, gastrointestinal (eg, Crohn disease, ulcerative colitis), inflammatory, neoplastic, neurologic (eg, multiple sclerosis), rheumatic (eg, antineutrophil cytoplasmic antibody-associated vasculitis, dermatomyositis/polymyositis, gout [acute flare], mixed cryoglobulinemia syndrome, polyarteritis nodosa, rheumatoid arthritis, systemic lupus erythematosus), and/or autoimmune origin. ¤ CONTRAINDICATIONS: systemic fungal infection,hypersensitivity, ITP ¤ ADVERSE EVENTS: Pancreatitis, HTN, Weight loss, seizures, eosinophilia ¤ PREGNANCY: US FDA pregnancy category: C ¤ STD. DOSE: 80 to 100 mg IM once a week for 1 to 4 week ISOSEPTIC SHOCK-Riddhi 18
INJ DOXY 100MG iv OD(D1- D3) ¤ GENERIC: Doxycycline, ¤ CATEGORY:Antibiotic, Tetracycline Derivative ¤ MOA: Inhibits protein synthesis by binding with the 30S and possibly the 50S ribosomal subunit(s) of susceptible bacteria; may also cause alterations in the cytoplasmic membrane ¤ INDICATIONS: Treatment of infections caused by Escherichia coli, Enterobacter aerogenes, Shigella spp., Acinetobacter spp., Klebsiella spp. (respiratory and urinary infections), and Bacteroides spp.; Neisseria meningitidis (when penicillin is contraindicated), STDs, Skin and skin structure infections ¤ CONTRAINDICATIONS: Use in infants and children <8 years of age or during second or third trimester of pregnancy; breast-feeding, Hypersensitivity ¤ ADVERSE EVENTS: Benign intracranial hypertension resulting in permanent loss of vision, superficial tooth discoloration, Bronchospasm, photosensitivity, Hyperpigmentation, Hypoglycemia ¤ PREGNANCY: US FDA pregnancy category: D ¤ STD. DOSE: Initial dose: 200 mg orally on the first day, given in 2 divided doses (100 mg every 12 hours) -Maintenance dose: 100 mg orally once a day OR 50 mg orally every 12 hours ---More severe infections: 100 mg orally every 12 hours EPTIC SHOCK-Riddhi 19
CAP ACOGUT 100mg BD(D1- D3) ¤ GENERIC: Acotiamide ¤ CATEGORY: an acetylcholinesterase inhibitor. ¤ MOA: Cholinesterase inhibitors block the action of the enzyme cholinesterase, which is responsible for breaking down acetylcholine. This increases levels of acetylcholine in the synaptic cleft ¤ INDICATIONS: treatment of postprandial fullness, upper abdominal bloating, and early satiation due to functional dyspepsia ¤ CONTRAINDICATIONS: NOT KNOWN ¤ ADVERSE EVENTS: constriction of the pupils in the eyes, increased secretion of sweat, saliva and tears, slow heart rate, mucus secretion in the respiratory tract and constriction of the airways. ¤ PREGNANCY: US FDA pregnancy category: not assigned ¤ STD. DOSE: 100-200 mg/day ISOSEPTIC SHOCK-Riddhi 20
SYP ULGEL 2tsp TDS(D2-D3) ¤ GENERIC: Magaldrate + Semithicone ¤ CATEGORY: Antiflatulent ¤ MOA: Decreases the surface tension of gas bubbles thereby disperses and prevents gas pockets in the GI system ¤ INDICATIONS: dyspepsia, gastrointestinal discomfort, bloating, discomfort of GI region ¤ CONTRAINDICATIONS: Hypersensitivity ¤ ADVERSE EVENTS: Pruritis, constipation ¤ PREGNANCY: US FDA pregnancy category: Not formally assigned to a pregnancy category. ¤ STD. DOSE:1 to 2 teaspoonfuls after meals and at bedtime ISOSEPTIC SHOCK-Riddhi 21
SYP CREMAFFIN 1tsp HS(D1- D3) ¤ GENERIC: liquid paraffin (1.25 ml), magnesium hydroxide or milk of magnesia (3.75 ml) and sodium picosulfate (3.33 mg) ¤ CATEGORY: Laxative ¤ MOA: Promotes bowel evacuation by causing osmotic retention of fluid which distends the colon with increased peristaltic activity; reacts with hydrochloric acid in stomach to form magnesium chloride ¤ INDICATIONS: Constipation, improper bowel movement, colonoscopy ¤ CONTRAINDICATIONS: Anorexia Nervosa, Diarrhoea, pregnancy, lactation ¤ ADVERSE EVENTS: fatigue, Dizziness , Diarhhoea, Cramps, and stomach aches, anorexia ¤ PREGNANCY: US FDA pregnancy category: Not formally assigned to a pregnancy category. ¤ STD. DOSE: 3600 to 7200 mg (as magnesium hydroxide) orally per day, given once a day in divided doses, or as directed -Maximum dose: 7200 mg/day -Duration of therapy: Up to 7 days ISOSEPTIC SHOCK-Riddhi 22
INJ CALCIUM GLUCONATE 1g OD(D1-D3) ¤ CATEGORY: Calcium supplement,replacement ¤ MOA: Moderates nerve and muscle performance via action potential threshold regulation ¤ INDICATIONS: Dietary calcium supplementation, CCB overdose ¤ CONTRAINDICATIONS: Hypercalcemia; concomitant use of IV calcium gluconate with ceftriaxone in neonates (≤28 days of age) ¤ ADVERSE EVENTS: weakness, confusion, feeling tired, headache, upset stomach , vomitting, constipation, or bone pain. ¤ PREGNANCY: US FDA pregnancy category: Not assigned ¤ STD. DOSE: Initial dose: 1000 to 2000 mg intravenously (IV) Subsequent doses (as needed): -IV bolus: 1000 to 2000 mg every 6 hours -Continuous IV infusion: Initiate at 5.4 to 21.5 mg/kg/hour Maximum IV bolus infusion rate: 200 mg/min ISOSEPTIC SHOCK-Riddhi 23
Aloe vera juice 20ml daily(D1-D3) ¤ MOA: unknown ¤ INDICATIONS: to inhibit infection and promote healing, sunburn, eczema ¤ CONTRAINDICATIONS: Ingestion is contraindicated in women who are pregnant or breast-feeding, children younger than 12 years of age, and elderly patients with suspected intestinal obstruction ¤ ADVERSE EVENTS: mild itching or burning ¤ PREGNANCY: Cathartic, reputed abortifacient. ¤ STD. DOSE: topical- max 500mg ISOSEPTIC SHOCK-Riddhi 25
ISOSEPTIC SHOCK-Riddhi 26
✔ Add Title ✔ Add Title ✔ Add Title ✔ Add Title ✔ Add Title ✔ Add Title PATIENT NAME: XYZ HOSP. NO: AGE: yr WEIGHT: kg SEX: M/F:Male DATE OF ADMISSION: 11 /02/18 DATE OF DISCHARGE: 14/02/18 COMPLAINTS ON ADMISSION : ∙ MEDICAL HISTORY : MEDICATION HISTORY : - SOCIAL HISTORY: FAMILY HISTORY: NS PREVIOUS ALLERGIES: N/S PHYSICAL EXAMINATION: moderately build and nourished, conscious and co-operative GENERAL - no P I C C L E VITAL SIGNS - PR: 90 /min ; BP : 110/80mmhg, R.R:- N/A, HEENT - N/S CVS - S1 S2 heard; no murmurs RS - N/S GIT - N/S GU - N/S EXT - reflexes were normal. CNS - conscious and oriented PROVISIONAL DIAGNOSIS: ROUTINE BIOCHEMICAL INVESTIGATIONS HAEMATOLOGY: Urea: mg/dl S.Cr :mg/dl Na: mEq/L K: mEq/L FBS: PPBS: RBS: Tch : TGs : T Bili: D Bili: T. Prot: Al b: Gl ob : AS T: AL T: AL P: RBC : Retics: WBC: Hb: N: PCV: L: MCV: M: MCH: E: MCHC: B: ESR: Platelets:. URINE ANALYSIS OTHERS pH: WBC: Protein RBC: Sugars: EP. Blood: Casts: Crystals: Stool – ECG - FINAL DIAGNOSIS:- Acute wall MI DRUG WITH DOSE & ROUTE DURATION OF THERAPY GENERIC NAME BRAND NAME 1 2 3 4 5 6 7 8 9 8 8 √ √ √ √ √ √ √ √ √ √ √ √ √ √ DISCHARGE MEDICATIONS: DISCHARGE MEDICATIONS: Patient not discharged DAY INVESTIGATIONS D1 D2 D3 PR – beats/min BP – mmHg PR – 80 beats/min BP – mmHg PR – 86 beats/min BP – 100/80 mmHg REVIEW: Visit after 1 week DRUG TREATMENT CHART: PROGRESS CHART: PPF Medication Dose and duration 1 2 3 4 5
PLANNING ❖ THERAPEUTIC MONITORING: ❖ TOXICITY MONITORING: ❖ DISCHARGE MONITORING: ❖ DISCHARGE MEDICATIONS: ISOSEPTIC SHOCK-Riddhi 28
POINT TO PATIENT ❖ About the disease: ❖ About lifestyle modifications: ❖ About medications: ISOSEPTIC SHOCK-Riddhi 29
POINT TO physician � ADJUST DOSING INTERVAL: Administration of a tetracycline with aluminum, calcium, or magnesium salts significantly decreases tetracycline serum concentrations. The proposed mechanism is chelation of tetracycline by the cation, forming an insoluble complex that is poorly absorbed from the gastrointestinal tract. MANAGEMENT: The administration of tetracyclines and preparations containing aluminum, magnesium, or calcium should be separated by two to four hours. � MONITOR: Coadministration of a tetracycline may decrease theophylline plasma clearance and increase theophylline levels. The mechanism is unknown. MANAGEMENT: If these drugs are given concurrently, close clinical and laboratory monitoring of response and tolerance is recommended. ISOSEPTIC SHOCK-Riddhi 30
POINT TO physician � CONTRAINDICATED: Coadministration of ceftriaxone with calcium-containing solutions, even via different infusion lines, may cause precipitation of ceftriaxone-calcium salt. � MONITOR: Bowel cleansing as well as overuse of certain laxatives may cause electrolyte loss and increase the risk of torsade de pointes ventricular arrhythmia in patients treated with drugs that prolong the QT interval. � MONITOR: Proton pump inhibitors may increase the rate of theophylline absorption from sustained- release formulations. Chronic use of proton pump inhibitors produce sustained hypochlorhydria, which may enhance peristalsis in the small intestine and antiperistalsis in the proximal colon where theophylline is absorbed.MANAGEMENT: Patients should be advised to report any signs of theophylline toxicity including nausea, vomiting, diarrhea, headache, restlessness, insomnia, or irregular heartbeat to their physicians. � MONITOR: The concomitant use of theophylline and corticosteroids may theoretically increase the risk of hypokalemia due to additive potassium-lowering effects. MANAGEMENT: Monitoring for altered efficacy and safety of theophylline and altered serum potassium and theophylline concentrations is advisable when these drugs are coadministered. � MONITOR: Chronic use of proton pump inhibitors (PPIs) may induce hypomagnesemia, and the risk may be increased during concomitant use of diuretics or other agents that can cause magnesium loss. Hypomagnesemia can also cause impaired parathyroid hormone secretion, which may lead to hypocalcemia. MANAGEMENT: Monitoring of serum magnesium levels is recommended prior to initiation of therapy and periodically thereafter if prolonged treatment with a proton pump inhibitor is anticipated or when combined with other agents that can cause hypomagnesemia such as diuretics ISOSEPTIC SHOCK-Riddhi 31

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Isoseptic shock.ppt

  • 2. SUBJECTIVE DATA NAME: QRS AGE: 67 SEX: M Weight: 65 kg Height: 188cms DOA: 21/10/19 � CHIEF COMPLAINTS: i. Dyspnea ii. Constipation iii. Anorexia iv. Abdominal pain v. Headache ISOSEPTIC SHOCK-Riddhi 2
  • 3. OBJECTIVE DATA � MEDICAL H/O: Herpes-Zoster No h/o DM,HTN � MEDICATION H/O: 3 haemodialysis done ▪ [Redicate Clav]Cefixime (200 mg) + Clavulanic Acid (125 mg) ▪ [Tb Soft Cold] Chlorpheniramine maleate 2 MG +Paracetamol 125 MG +Phenylephrine 5 MG ▪ [Rabepraz] Rabeprazole 10 MG � SOCIAL H/O: Married, Farmer � FAMILY H/O: N/S � PREVIOUS ALLERGIES: N/S ISOSEPTIC SHOCK-Riddhi 3
  • 4. PHYSICAL EXAMINATION GENERAL: stable VITALS: BP-140/90 Pulse: 130/min SpO2: % RR: /min HEENT: N CVS: N CNS: semiconscious, oriented GIT: discomfort, tender,palpated GU: N EXT: Left ankle area – dry wound ++ ISOSEPTIC SHOCK-Riddhi 4
  • 5. Lab investigations: CBC D1 D3 D5 Hb(12- 16g/Dl) 12.3 9.9 11.9 RBC(4-5.5 10^12/L) 4.32 27.1 4.10 WBC(4- 10)10^9/L 16.36 24.70 15.91 NEUT (2- 7)10^9/L 15.35 22.17 14.34 LYM(0.8- 4)10^9/L 0.5 0.89 0.69 PLT (100- 450)10^3/uL 37 162 33 ISOSEPTIC SHOCK-Riddhi 5
  • 6. Lab investigations P.S EXAM ❖ WBC: Neutrophilic leukocytosis ❖ RBC: hypochromic+, microcytic+, anisocytosis+ ❖ PLT: decreased on smear; no evidence of MP SERUM ELECTROLYTES D1 D2 D3 S. Na 114 117 125 S.K 5.7 5.9 5.9 ISOSEPTIC SHOCK-Riddhi 6
  • 7. Lab investigations Routine Analysis ▪ S.BUN- 69.0mg/dL (5-25mg/dL) ▪ S.Creat- 5.6mg/dL (0.8-1.4mg/dL) ▪ SGPT- 29.4 U/L (upto 40 IU/L) ▪ D.Bil- 1.5 mg/dL(0-0.4mg/dL) ▪ I.Bil- 1.80 mg/dL(0.4-1.3mg/dL) ▪ T.Bil-3.30mg/dL(mg/dL) ▪ ALP- 236.7IU/L (60-170 IU/L) ▪ S.Alb- 2.2g/dL(3.8-5 g/dL) ▪ S.Glob-2.2g/dL(2.3-3.5g/dL) ▪ T.Prot: 4.4g/dL (6-8 g/dL) ▪ Procalcitonin:56.8 ng/ml (0.15- 0.50 ng/Ml) ▪ RBG: 116 mg/dL(60-120 mg/dL) ABG ▪ pH-7.27 ▪ pCO2- 28 mm Hg ▪ pO2- 88 mm Hg ▪ HCO3- 12.9mmol/L ▪ TCO2- 13.8mmol/L ▪ Beb- -12.6mmol/L ▪ BEecf- -14.0mmol/L ISOSEPTIC SHOCK-Riddhi 7
  • 8. Lab investigations: URINALYSIS � SUGAR: Nil � ALBUMIN: +ve � 80-90 pus cells with 1-2 RBCs USG � Both kidneys enlarged in size with grade II raised cortical echogenicity � ARF � Mild hepatomegaly � Mild splenomegaly ISOSEPTIC SHOCK-Riddhi 8
  • 9. Lab investigations STRESS TEST � 0.84 kms( 11 mins) � Max HR: 146 bpm � Max BP: 164/90 � Mild ST Depression � Negative for exercise induced cardiac ischemia C-XR � Normal chest radiograph. � No significant findings ISOSEPTIC SHOCK-Riddhi 9
  • 10. Lab investigations Leptospira � IgM: -ve � IgG: -ve HbsAg & HIV tridot � NEGATIVE ISOSEPTIC SHOCK-Riddhi 10
  • 11. ASSESSMENT ❖ FINAL DIAGNOSIS: ISOSEPTIC SHOCK WITH ARF ❖ ETIOLOGY: UNKNOWN ❖ GOALS OF THERAPY: I. To increase quality of life II. Prevent comorbidity, mortality & further progression of disorder III. Reduce adverse events of current therapy and optimize therapy ISOSEPTIC SHOCK-Riddhi 11
  • 12. PAN 40 mg IV OD(D1-D3) ¤ Generic– Pantoprazole ¤ Category- Proton pump inhibitor ¤ MOA–It is a proton pump inhibitor,inhibits H,K ATPase enzyme which secretes HCl in parietel cells of stomach ¤ Indications-Ulcers and reflux oesophagitis,GERD,Zollinger-Ellison syndrome ¤ Contraindication- Hypersensitivity ¤ Side effects- Headache, diarrhea, dizziness ¤ Pregnancy–US FDA pregnancy category Not Assigned:This drug is only recommended for use during pregnancy when there are no alternatives and the benefit outweighs the risk. ¤ Warnings–Prolonged treatment (greater than 24-36 months) may cause vitamin B12 deficiency. ¤ Std. Dose–20-80 mg/day ISOSEPTIC SHOCK-Riddhi 12
  • 13. EMESET 4mg IV BD(D1-D3) ¤ GENERIC: Ondansetron ¤ CATEGORY- Anti emetic ¤ MOA: Ondansetron is a selective 5-HT3-receptor antagonist which blocks serotonin, both peripherally on vagal nerve terminals and centrally in the chemoreceptor trigger zone ¤ INDICATIONS: CINV, Post operative nausea/vomitting,pregnancy associated nausea,vomitting. Gastric pareisis ¤ CONTRAINDICATIONS: Hypersensitivity, concomitant use with apomorphine ¤ ADVERSE EVENTS: confusion, dizziness, fever, fatigue, gastric pain ¤ PREGNANCY: US FDA pregnancy category: B ¤ STD. DOSE: recommended dose: 0.15 mg/kg IV, with the first dose (infused over 15 minutes) 30 minutes before the start of emetogenic chemotherapy and subsequent doses given 4 and 8 hours after the first dose. -Maximum dose: 16 mg per dose ISOSEPTIC SHOCK-Riddhi 13
  • 14. INJ DERIPHYLLN 1amp STAT & OD(D1-D3) ¤ GENERIC: Etophylline (84.7mg) + Theophylline( 25.3mg) ¤ CATEGORY- Bronchodilator ¤ MOA: smooth muscle relaxation (ie, bronchodilation) and suppression of the response of the airways to stimuli (ie, non-bronchodilator prophylactic effects). Bronchodilation is mediated by inhibition of two isoenzymes, phosphodiesterase (PDE III and, to a lesser extent, PDE IV) ¤ INDICATIONS: asthma, bronchitis, COPD,bradycardia ¤ CONTRAINDICATIONS: allergy, Hypersensitivity to xanthine derivatives; coronary artery disease (where cardiac stimulation might prove harmful); peptic ulcers; coadministration with ephedrine in children. ¤ ADVERSE EVENTS: acid base imbalance, irregular heartbeat, persistent vomitting,diuresis, ¤ PREGNANCY: US FDA pregnancy category C ¤ STD. DOSE: Initial dose: 200 mg per day given as evenly divided doses every 6 to 8 hours After 3 days, if starting dose was tolerated: 100 mg per day given as evenly divided doses every 6 to 8 hours ISOSEPTIC SHOCK-Riddhi 14
  • 15. INJ LASIX 10mg IV stat(D1) ¤ GENERIC: FUROSEMIDE ¤ CATEGORY- Diuretic ¤ MOA: Primarily inhibits reabsorption of sodium and chloride in the ascending loop of Henle and proximal and distal renal tubules, interfering with the chloride-binding cotransport system, thus causing its natriuretic effect ¤ INDICATIONS: Management of edema associated with heart failure, cirrhosis of the liver (ie, ascites), or renal disease (including nephrotic syndrome); acute pulmonary edema. ¤ CONTRAINDICATIONS: Hypersensitivity to sulfonamide-derived drugs; complete renal shutdown; hepatic coma and precoma; uncorrected states of electrolyte depletion, hypovolemia, dehydration, hyperbilirubinemiaor hypoten ¤ ADVERSE EVENTS: electrolyte depletion, painful urination, syncope, SIADH ¤ PRECAUTIONS: Furosemide is a potent diuretic which, if given in excessive amounts, can lead to a profound diuresis with water and electrolyte depletion. ¤ PREGNANCY: US FDA pregnancy category C ¤ STD. DOSE: Initial dose: 20 to 40 mg IV (slowly over 1 to 2 minutes) or IM once; may repeat with the same dose or increase by 20 mg no sooner than 2 hours after the previous dose until the desired diuretic effect has been obtained. Maintenance dose: Administer the dose that provided the desired diuretic effect once or twice a day. ISOSEPTIC SHOCK-Riddhi 15
  • 16. INJ MONTAZ 1g iv BD(D1- D3) ¤ GENERIC: Ceftriaxone(1000mg) + Tazobactam(125mg) ¤ CATEGORY: Bactericidal,Cephalosporin ¤ MOA: Inhibits bacterial cell wall synthesis by binding to one or more of the penicillin- binding proteins (PBPs) ¤ INDICATIONS: Pyelonephritis, noscomical pneumonia, UTI, ¤ CONTRAINDICATIONS: hypersensitivity to ceftolozane/tazobactam, piperacillin/tazobactam, other members of the beta-lactam class ¤ ADVERSE EVENTS: Fever, irregular heartbeat, dizziness, abdominal pain ¤ PREGNANCY: US FDA pregnancy category Not Assigned ¤ STD. DOSE: 1.5 g IV every 8 hours Duration of therapy: 7 days ISOSEPTIC SHOCK-Riddhi 16
  • 17. INJ BUSCOPAN 1g IV STAT(D1) ¤ GENERIC: Hyoscine Butylbromide, Scopolamine ¤ CATEGORY: Anticholinergic Agent ¤ MOA: blocks the action of acetylcholine at parasympathetic sites in smooth muscle, secretory glands and the CNS; increases cardiac output, dries secretions, antagonizes histamine and serotonin; at usual recommended doses, causes blockade of muscarinic receptors at the cardiac SA-node and is parasympatholytic ¤ INDICATIONS: Motion sickness, treatment of smooth muscle spasm of the genitourinary or GI tract,adjunct to anaesthesia ¤ CONTRAINDICATIONS: Untreated narrow-angle glaucoma; megacolon, prostatic hypertrophy with urinary retention; stenotic lesions or mechanical stenosis of the GI tract; myasthenia gravis; tachycardia, angina, heart failure; paralytic or obstructive ileus; IM administration in patients receiving anticoagulant therapy ¤ ADVERSE EVENTS: drowsiness and xerostomia, dilation of pupils,migraine, cycloplegia ¤ PREGNANCY: US FDA pregnancy category: C ¤ STD. DOSE: IM, IV, SubQ: 10 to 20 mg; maximum: 100 mg/day ISOSEPTIC SHOCK-Riddhi 17
  • 18. HYDROCORTISONE 100mg 1amp iv STAT(D1) ¤ CATEGORY: Corticosteroid, Systemic ¤ MOA:May depress the formation, release, and activity of endogenous chemical mediators of inflammation (kinins, histamine, liposomal enzymes, prostaglandins) through the induction of phospholipase A2 inhibitory proteins (lipocortins) and sequential inhibition of the release of arachidonic acid. Hydrocortisone has low to intermediate range potency (dosage-form dependent). ¤ INDICATIONS: immune thrombocytopenia, warm autoimmune hemolytic anemia), allergic, gastrointestinal (eg, Crohn disease, ulcerative colitis), inflammatory, neoplastic, neurologic (eg, multiple sclerosis), rheumatic (eg, antineutrophil cytoplasmic antibody-associated vasculitis, dermatomyositis/polymyositis, gout [acute flare], mixed cryoglobulinemia syndrome, polyarteritis nodosa, rheumatoid arthritis, systemic lupus erythematosus), and/or autoimmune origin. ¤ CONTRAINDICATIONS: systemic fungal infection,hypersensitivity, ITP ¤ ADVERSE EVENTS: Pancreatitis, HTN, Weight loss, seizures, eosinophilia ¤ PREGNANCY: US FDA pregnancy category: C ¤ STD. DOSE: 80 to 100 mg IM once a week for 1 to 4 week ISOSEPTIC SHOCK-Riddhi 18
  • 19. INJ DOXY 100MG iv OD(D1- D3) ¤ GENERIC: Doxycycline, ¤ CATEGORY:Antibiotic, Tetracycline Derivative ¤ MOA: Inhibits protein synthesis by binding with the 30S and possibly the 50S ribosomal subunit(s) of susceptible bacteria; may also cause alterations in the cytoplasmic membrane ¤ INDICATIONS: Treatment of infections caused by Escherichia coli, Enterobacter aerogenes, Shigella spp., Acinetobacter spp., Klebsiella spp. (respiratory and urinary infections), and Bacteroides spp.; Neisseria meningitidis (when penicillin is contraindicated), STDs, Skin and skin structure infections ¤ CONTRAINDICATIONS: Use in infants and children <8 years of age or during second or third trimester of pregnancy; breast-feeding, Hypersensitivity ¤ ADVERSE EVENTS: Benign intracranial hypertension resulting in permanent loss of vision, superficial tooth discoloration, Bronchospasm, photosensitivity, Hyperpigmentation, Hypoglycemia ¤ PREGNANCY: US FDA pregnancy category: D ¤ STD. DOSE: Initial dose: 200 mg orally on the first day, given in 2 divided doses (100 mg every 12 hours) -Maintenance dose: 100 mg orally once a day OR 50 mg orally every 12 hours ---More severe infections: 100 mg orally every 12 hours EPTIC SHOCK-Riddhi 19
  • 20. CAP ACOGUT 100mg BD(D1- D3) ¤ GENERIC: Acotiamide ¤ CATEGORY: an acetylcholinesterase inhibitor. ¤ MOA: Cholinesterase inhibitors block the action of the enzyme cholinesterase, which is responsible for breaking down acetylcholine. This increases levels of acetylcholine in the synaptic cleft ¤ INDICATIONS: treatment of postprandial fullness, upper abdominal bloating, and early satiation due to functional dyspepsia ¤ CONTRAINDICATIONS: NOT KNOWN ¤ ADVERSE EVENTS: constriction of the pupils in the eyes, increased secretion of sweat, saliva and tears, slow heart rate, mucus secretion in the respiratory tract and constriction of the airways. ¤ PREGNANCY: US FDA pregnancy category: not assigned ¤ STD. DOSE: 100-200 mg/day ISOSEPTIC SHOCK-Riddhi 20
  • 21. SYP ULGEL 2tsp TDS(D2-D3) ¤ GENERIC: Magaldrate + Semithicone ¤ CATEGORY: Antiflatulent ¤ MOA: Decreases the surface tension of gas bubbles thereby disperses and prevents gas pockets in the GI system ¤ INDICATIONS: dyspepsia, gastrointestinal discomfort, bloating, discomfort of GI region ¤ CONTRAINDICATIONS: Hypersensitivity ¤ ADVERSE EVENTS: Pruritis, constipation ¤ PREGNANCY: US FDA pregnancy category: Not formally assigned to a pregnancy category. ¤ STD. DOSE:1 to 2 teaspoonfuls after meals and at bedtime ISOSEPTIC SHOCK-Riddhi 21
  • 22. SYP CREMAFFIN 1tsp HS(D1- D3) ¤ GENERIC: liquid paraffin (1.25 ml), magnesium hydroxide or milk of magnesia (3.75 ml) and sodium picosulfate (3.33 mg) ¤ CATEGORY: Laxative ¤ MOA: Promotes bowel evacuation by causing osmotic retention of fluid which distends the colon with increased peristaltic activity; reacts with hydrochloric acid in stomach to form magnesium chloride ¤ INDICATIONS: Constipation, improper bowel movement, colonoscopy ¤ CONTRAINDICATIONS: Anorexia Nervosa, Diarrhoea, pregnancy, lactation ¤ ADVERSE EVENTS: fatigue, Dizziness , Diarhhoea, Cramps, and stomach aches, anorexia ¤ PREGNANCY: US FDA pregnancy category: Not formally assigned to a pregnancy category. ¤ STD. DOSE: 3600 to 7200 mg (as magnesium hydroxide) orally per day, given once a day in divided doses, or as directed -Maximum dose: 7200 mg/day -Duration of therapy: Up to 7 days ISOSEPTIC SHOCK-Riddhi 22
  • 23. INJ CALCIUM GLUCONATE 1g OD(D1-D3) ¤ CATEGORY: Calcium supplement,replacement ¤ MOA: Moderates nerve and muscle performance via action potential threshold regulation ¤ INDICATIONS: Dietary calcium supplementation, CCB overdose ¤ CONTRAINDICATIONS: Hypercalcemia; concomitant use of IV calcium gluconate with ceftriaxone in neonates (≤28 days of age) ¤ ADVERSE EVENTS: weakness, confusion, feeling tired, headache, upset stomach , vomitting, constipation, or bone pain. ¤ PREGNANCY: US FDA pregnancy category: Not assigned ¤ STD. DOSE: Initial dose: 1000 to 2000 mg intravenously (IV) Subsequent doses (as needed): -IV bolus: 1000 to 2000 mg every 6 hours -Continuous IV infusion: Initiate at 5.4 to 21.5 mg/kg/hour Maximum IV bolus infusion rate: 200 mg/min ISOSEPTIC SHOCK-Riddhi 23
  • 24. Aloe vera juice 20ml daily(D1-D3) ¤ MOA: unknown ¤ INDICATIONS: to inhibit infection and promote healing, sunburn, eczema ¤ CONTRAINDICATIONS: Ingestion is contraindicated in women who are pregnant or breast-feeding, children younger than 12 years of age, and elderly patients with suspected intestinal obstruction ¤ ADVERSE EVENTS: mild itching or burning ¤ PREGNANCY: Cathartic, reputed abortifacient. ¤ STD. DOSE: topical- max 500mg ISOSEPTIC SHOCK-Riddhi 25
  • 26. ✔ Add Title ✔ Add Title ✔ Add Title ✔ Add Title ✔ Add Title ✔ Add Title PATIENT NAME: XYZ HOSP. NO: AGE: yr WEIGHT: kg SEX: M/F:Male DATE OF ADMISSION: 11 /02/18 DATE OF DISCHARGE: 14/02/18 COMPLAINTS ON ADMISSION : ∙ MEDICAL HISTORY : MEDICATION HISTORY : - SOCIAL HISTORY: FAMILY HISTORY: NS PREVIOUS ALLERGIES: N/S PHYSICAL EXAMINATION: moderately build and nourished, conscious and co-operative GENERAL - no P I C C L E VITAL SIGNS - PR: 90 /min ; BP : 110/80mmhg, R.R:- N/A, HEENT - N/S CVS - S1 S2 heard; no murmurs RS - N/S GIT - N/S GU - N/S EXT - reflexes were normal. CNS - conscious and oriented PROVISIONAL DIAGNOSIS: ROUTINE BIOCHEMICAL INVESTIGATIONS HAEMATOLOGY: Urea: mg/dl S.Cr :mg/dl Na: mEq/L K: mEq/L FBS: PPBS: RBS: Tch : TGs : T Bili: D Bili: T. Prot: Al b: Gl ob : AS T: AL T: AL P: RBC : Retics: WBC: Hb: N: PCV: L: MCV: M: MCH: E: MCHC: B: ESR: Platelets:. URINE ANALYSIS OTHERS pH: WBC: Protein RBC: Sugars: EP. Blood: Casts: Crystals: Stool – ECG - FINAL DIAGNOSIS:- Acute wall MI DRUG WITH DOSE & ROUTE DURATION OF THERAPY GENERIC NAME BRAND NAME 1 2 3 4 5 6 7 8 9 8 8 √ √ √ √ √ √ √ √ √ √ √ √ √ √ DISCHARGE MEDICATIONS: DISCHARGE MEDICATIONS: Patient not discharged DAY INVESTIGATIONS D1 D2 D3 PR – beats/min BP – mmHg PR – 80 beats/min BP – mmHg PR – 86 beats/min BP – 100/80 mmHg REVIEW: Visit after 1 week DRUG TREATMENT CHART: PROGRESS CHART: PPF Medication Dose and duration 1 2 3 4 5
  • 27. PLANNING ❖ THERAPEUTIC MONITORING: ❖ TOXICITY MONITORING: ❖ DISCHARGE MONITORING: ❖ DISCHARGE MEDICATIONS: ISOSEPTIC SHOCK-Riddhi 28
  • 28. POINT TO PATIENT ❖ About the disease: ❖ About lifestyle modifications: ❖ About medications: ISOSEPTIC SHOCK-Riddhi 29
  • 29. POINT TO physician � ADJUST DOSING INTERVAL: Administration of a tetracycline with aluminum, calcium, or magnesium salts significantly decreases tetracycline serum concentrations. The proposed mechanism is chelation of tetracycline by the cation, forming an insoluble complex that is poorly absorbed from the gastrointestinal tract. MANAGEMENT: The administration of tetracyclines and preparations containing aluminum, magnesium, or calcium should be separated by two to four hours. � MONITOR: Coadministration of a tetracycline may decrease theophylline plasma clearance and increase theophylline levels. The mechanism is unknown. MANAGEMENT: If these drugs are given concurrently, close clinical and laboratory monitoring of response and tolerance is recommended. ISOSEPTIC SHOCK-Riddhi 30
  • 30. POINT TO physician � CONTRAINDICATED: Coadministration of ceftriaxone with calcium-containing solutions, even via different infusion lines, may cause precipitation of ceftriaxone-calcium salt. � MONITOR: Bowel cleansing as well as overuse of certain laxatives may cause electrolyte loss and increase the risk of torsade de pointes ventricular arrhythmia in patients treated with drugs that prolong the QT interval. � MONITOR: Proton pump inhibitors may increase the rate of theophylline absorption from sustained- release formulations. Chronic use of proton pump inhibitors produce sustained hypochlorhydria, which may enhance peristalsis in the small intestine and antiperistalsis in the proximal colon where theophylline is absorbed.MANAGEMENT: Patients should be advised to report any signs of theophylline toxicity including nausea, vomiting, diarrhea, headache, restlessness, insomnia, or irregular heartbeat to their physicians. � MONITOR: The concomitant use of theophylline and corticosteroids may theoretically increase the risk of hypokalemia due to additive potassium-lowering effects. MANAGEMENT: Monitoring for altered efficacy and safety of theophylline and altered serum potassium and theophylline concentrations is advisable when these drugs are coadministered. � MONITOR: Chronic use of proton pump inhibitors (PPIs) may induce hypomagnesemia, and the risk may be increased during concomitant use of diuretics or other agents that can cause magnesium loss. Hypomagnesemia can also cause impaired parathyroid hormone secretion, which may lead to hypocalcemia. MANAGEMENT: Monitoring of serum magnesium levels is recommended prior to initiation of therapy and periodically thereafter if prolonged treatment with a proton pump inhibitor is anticipated or when combined with other agents that can cause hypomagnesemia such as diuretics ISOSEPTIC SHOCK-Riddhi 31