Sepsis from Complicated Urinary Tract Infection (with DRP: Sub-

therapeutic dosage; Dosage too low need to addition of ciprofloxacin

1
for home Medication) and Hypo-Natremia from Uncontrolled type 2
Diabetes without DRP
Subjective data:
52

HPI:
1

SH:

FM:

Objective data:
PMH: - (Diabetes Type 2 )

ALL: Cloxacillin MP Rash

MED: 23/6/2560

1. tramadol 50 cap 1 q8 hr
2. paracetamol 500 mg 1 prn
3. Mixtard 70/30 100 UI (3ml/ampule ) 20-0-10 u
4. B-com 1 3

PE: 169 . 49 ., BMI 17.156, BP 100/60 mmHg, PR 122/min,

RR 20/min, H&L: WNL

LAB: V/S

28/6/60 29/6/60 30/6/60 1/7/60 2/7/60 3/7/60 4/7/60

LAB

Respiration 24 21 22 24 22 20 20

BT 39.1 38.3 37.8 37.5 36.8 37.3 37.6

RR 122 120 85 87 83 78 75

systolic 123 141 132 140 140 130 148 129 140 150 144 140 130 1

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Diastolic 77 81 90 70 90 90 95 85 80 99 96 80 85 8
BP

Pain Score 0 0 2 2 2 2 -

Bacteriology 28/6/60 Urine Culture 30/6/60

Bacterial Identification & Sensitivity (NHS) Specimen:

...........Urine in sterile container

Collected: 28/6/60 22.30 Culture: No growth after 2

days

Specimen: ...........Hemo No.1

Gram stain: Gram positive bacilli

Stool Examination (SE) 30/6/60 ( 29/6/60

2
SE )

Character Solf

Color Green

Red blood cells 0-1

White blood cells 0-1

Parasites or Ova Not Found

DTX

28/6/60 29/6/60 30/6/60 1/7/60 2/7/60 3/7/60 4/7/60

06.00 - 93 131 132 149 167 239

11.45 252 75 179 128 117 77 -

16.00 203 241 284 251 250 304 -

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20.00 165 109 350 223 227 93 -

52 49 .. Cr 0.84 mg/dl
- MDRD (Modification of Diet in Renal Disease)
GFR (ml/min/1.73 m2) = 175 x (Scr : mg/dl)-1.154 x (age)-0.203
x (0.742 if female) x
GFR = 95.9557 ml/min/1.73 m2

HEMATOLOGY

28/6/60

10.00 .
LAB

Red blood cell

[M; 4.2-6.3 F; 4.2-5.5 3.93
(106 /uL)]

Hemoglobin 11.3
[M; 13-18 F; 12-16 (g
/dl)]

Hematocrit 31.2

[M; 40-54 F; 37-47

(%)]

MCV [80-100 (fl)] 79.4

MCH [27-33(pg)] 28.8

MCHC [31-35(g /dl)] 36.2

RDW-CV [11.5-14.5 12.0

(%)]

Platelet count 402

[150-450 (103 /uL)]

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platelet smear adequate

[adequate]

White Blood Cells 11.09

[4.5-10 (103 /uL)]

Neutrophils [40-70 79
(%)]

Lymphocytes [20-50 13
(%)]

Eosinophils [0-3 (%)] 0

Monocytes [2-10 (%)] 8

BIOCHEMISTRY

28/6/60 29/6/60 30/7/60

LAB

10.00 22.28 07.12 7.35

.

Calcium (Ca++) 8.6 8.3 - -

[8.4-10.2 (mg/dl)]

Magnesium (Mg++) 1.7 1.7 - -

[1.6-2.3 (mg/dl)]

Phosphorus 3.5 3.1 - -

[2.5-4.5 (mg/dl)]

Albumin [3.5-5 (g/dl)] - 3.1 - -

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Bun 10.6 - - -
[M;9-20,F;7-17 (mg/dl)]

Electrolytes

Sodium (Na+) [137-145 124 - 126 130

(mmol/L)]

Potassium (K+) [3.5- 4.0 - 3.8 3.3

5.1 (mmol/L)]

Chloride (Cl-) [98-107 89 - 91 95

(mmol/L)]

Total CO2[22-30 25 - 26 24
(mmol/L)]

Creatinine

Creatinine 0.84 - - -
[M;0.66-1.25,F;0.52-
1.04 (mg/dl)]

eGFR using CKD-EPI 100.67 - - -

[ 90mL/min/1.732 m2
]

BIOCHEMISTRY 28/6/60

Serum ketone [ 5 5
(mg/dl) ]

TSH [ 0.465-4.68 0.979

(mg/dl) ]

Free T3 [ 2.77-5.27 2.18

(pg/ml) ]

Free T4 [ 0.78-2.19 1.86

(ng/dl) ]

SOAP NOTE : .
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MICROSCOPY

29/6/60 1/7/60 3/7/60

LAB 7.12 07.07 07.42

color Yellow colorless Light yellow

(colorless-yellow)

Appearance [Clear] Turbid Clear Clear

PH[6-8] 6 7 7

Sp.gr [1.010-1.025] 1.005 1.004 1.005

Urine albumin Trace Negative Negative

[Negative]

Urine Sugar Negative 1+ 2+

[Negative]

Urine Ketones 1+ Negative Negative

[Negative]

Urine Blood Trace Negative Negative

[Negative]

Urine Urobilinogen Normal Normal Normal

[Normal]

Urine Bilirubin Negative Negative Negative

[Negative]

Urine Nitrite Negative Negative Negative

[Negative]

Urine Leukocyte 3+ 2+ 2+
[Negative]

Medication:

SOAP NOTE : .
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28/6/6 29/6/6 30/6/ 1/7/60 2/7/6 3/7/6 4/7/60
0 0 60 0 0

0.9 % NSS 1000 ml

@12 / /
@2 , @10 / OFF
V rate 80 ml / hr = V rate
60 ml / hr @19/

3% NaCl 500 ml V 40 ml / @16 /

hr x 4hr

Elixir KCl 30 ml Stat

@10 /
Mixtard 20-0-10 SC ac -/ // /
7,16
OFF

Mixtard 20-0-8 SC ac
-/ / OFF
7,16

Mixtard 18-0-8 SC ac
-/ // // /
7,16

RI 6 U SC ac 16
/
NPH 4 U SC 20
/
Cef-3 2gm iv OD Stat 10 OFF !

Clindamycin 600mg V q
@23 / //
8hr 6,14,22
OFF

Ciprofloxacin 400mg V q
12hr 6,18
-/ /? // // // /
drip1hr

**IV
push** phlebitis

B1-6-12 1 tab x 3 pc
- // /// //? /// /// /// /
8,12,17

SOAP NOTE : .
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- // /// //? /// /// /// /

(FF) Ferrous Fumarate
200 mg. tab
1 tab x 3 pc 8,12,17

Folic acid 5 mg 1 tab x 1

@12 / / / / / / /
pc 8

Paracetamol 500 mg 1 tab

/
q4 hr 18,22

Assessment 1: Sepsis from Complicated Urinary Tract Infection

(with DRP: Sub-therapeutic dosage; Dosage too low need to
addition of ciprofloxacin for home Medication)
Etiology and risk factor
sepsis

( systemic
inflammatory response syndrome, SIRS) SIRS

SIRS 2 4

o 38.3 36
o HR 90
o RR 20
o 12,000 4,000


28/6/2560 39.1
C 122 Respiratory rate 24
11,090
sepsis


Gram positive bacilli
Urine albumin => Trace, Urine Ketones => 1+, Urine Blood => Trace

(Upper urinary
tract infection)
SOAP NOTE : .
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systemic Red blood cell

(3.93), Hemoglobin (11.3), Hematocrit (31.2), MCV
(79.4), MCHC (36.2), Lymphocytes (13),
White Blood Cells (11.09) Neutrophils (79)

( complicated urinary tract infections)





Sepsis Shock

Assessment severity of disease

- Surviving Sepsis Campaign 2016

severity
Sepsis

- severe sepsis septic

shock 2558 severity
Sepsis SIRS
2 4
( 39.1 C 122
Respiratory rate 24
11,090 )
SOAP NOTE : .
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Assessment if therapy is indicated

severe sepsis septic shock
2558

SOAP NOTE : .
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empirical therapy

empirical therapy

SOAP NOTE : .
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, ,
, ,
. Trends in Infectious Disease
Pharmacotherapy 2011. 2. :
, 2554.

cephalosporins quinolone Cef-3 2gm iv
OD Stat empirical therapy
Cloxacillin
Clindamycin 600mg V q 8hr

Assessment of current therapy

- C l i n d a m y c i n 6 0 0 m g V q 8 h r

Gram positive bacilli

Antibiogram 2 0 1 6 ( Jan-Sep) NARST C l i n d a m y c i n
Gram positive

- Staphylococcus aureus (all isolates)*

- Staphylococcus aureus, MRSA*
- Staphylococcus aureus, MSSA*
- Staphylococcus, coagulase negative (all
isolates)
-
Methicillin resistant, coagulase negative
Staphylococcus , MRCNS
SOAP NOTE : .
- Methicillin susceptible ,
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coagulase negative Staphylococcus ,
MSCNS
 13

*

sepsis

- Ferrous Fumarate 200 mg1 tab x 3 pc

- Folic acid 5 mg 1 tab x 1 pc

- B1-6-12 1 tab x 3 pc Diabetic

neuropath -

- Paracetamol 500 mg 1 tab q4 hr

Urine analysis 29/06/60

Urine albumin => Trace, Urine Ketones => 1+,
U r i n e B l o o d = > T r a c e

Clindamycin
600mg V q 8hr Ciprofloxacin 400mg V q 12hr drip 1hr
urine culture

SOAP NOTE : .
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, ,
, ,
. Trends in Infectious Disease
Pharmacotherapy 2011. 2. :
C i p r o f l o x a c i n 4 0 0 m g I V
, 2554. q12hr
10-14

30/6/60 :
Urine Culture 30/06/60

Specimen: ...........Urine in sterile container

Culture: No growth after 2 days

V / S discharge

Plan: Therapeutic plan

- Ciprofloxacin 400mg IV q 12hr drip 1hr

( discharge switch Ciprofloxacin 500mg Oral
10-14 )
- B1-6-12 1 tab x 3 pc
- (FF) Ferrous Fumarate 200 mg 1 tab x 3 pc
- Folic acid 5 mg 1 tab x 1 pc

discharge 4 / 7 / 6 0
Ciprofloxacin
Ciprofloxacin 500 mg q 12hr 14

SOAP NOTE : .
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Goals of treatment

- (Sepsis)
- Sepsis

Therapeutic monitoring parameters

- Hematology parameters
- Biochemistry parameters
Calcium (Ca++) [8.4-10.2 (mg/dl)]
Albumin [3.5-5 (g/dl)]
Sodium (Na+) [137-145 (mmol/L)]
Potassium (K+) [3.5-5.1 (mmol/L)]
Chloride (Cl-) [98-107 (mmol/L)]
Serum ketone [ > 5 (mg/dl) ]
Free T3 [ 2.77-5.27 (pg/ml) ]
- Microscopy Urine analysis
- < 140/90 mmHg
- sepsis <180 mg/dl

Toxic monitoring parameters

- Clindamycin : Nausea, vomiting, abdominal pain or cramps, taste

disturbances, oesophagitis
- Ferrous Fumarate: GI: Nausea, anorexia, vomiting, constipation
or diarrhoea, abdominal cramps, heartburn, black stool.
- Folic acid: GI disturbances, hypersensitivity reactions;
bronchospasm.
- Paracetamol: Thrombocytopenia, leucopenia, pancytopenia,
neutropenia, agranulocytosis, pain and burning sensation at inj
site. Rarely, hypotension and tachycardia.

Patient education

-
- 5
-

Future plan

SOAP NOTE : .
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- ,,,
,

Assessment 2: Hypo-Natremia from Uncontrolled type 2 Diabetes

without DRP

Etiology and risk factor

Hyponatremia Na+ < 1 3 5 mEq/L

Na+
N/V
-
3
- Euvolumic hypotonic hyponatremia Na+
BP HR
ADH ADH
ADH plasma
osmolality volume syndrome of inappropriate
secretion of ADH (SIADH) serum osmolality < 280
mOsm/kg urine sodium> 20 mmol
- Hypervolemic hypotonic hyponatremia H2O > Na+
(dilutional effect)
serum
osmolality< 280 mOsm/kg urine sodium < 10 mmol
- Hypovolemic hypotonic hyponatremia H2O Na+

BP HR , ,

, , ,
Addisons Dz, mineralocorticoid
renal tubular acidosis ( thiazide effect >loop
diuretics) urine sodium < 10 mmol = hyponatremia
urine sodium > 20 mmol
= , , renal tubular acidosis

SOAP NOTE : .
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hyponatremia

hyponatremia

Hyperglycemia
Hypothyroidism hyponatremia
True hyponatremia
Pseudo hyponatremia
hyponatremia
( Hyperglycemia)
70-99 mg/dl 8
2 1 8 0 m g / d l




osmotic diuresis

SOAP NOTE : .
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, ,
hyponatremia
100 mg/dl 100 mg/dl Serum Na
2.5 mmol/ mEq/L

2

28/6/60 DTX 252 mg/dl Biochemistry
parameters Na+ < 135 m m o l / L
-
Pseudo hyponatremia

Assessment if therapy is indicated

-
Na+
Na+
Na = 0.6 x BW x (plasma Na
Na )
Na
= ____ mEq/L,
= 49, Plasma Na = 135 mmol/L, Na

= 124 mmol/L
Na

= 323.4 mEq/L /day
- 2 9 / 6/ 6 0 2 S E

Biochemistry
Parameters 30/6/60 K+
(3.3) Elixir KCL

Lexi Comp. Drug information handbook. 24th Edition. United

K+ 3.3 mmol/dl

states: Lexi Comp Inc.; 2015


K+
Maximum infusion rate : 10 mEq/L/ hour, Maximum
concentration : 40 mEq/L,
Maximum 24-hour dose : 200 mEq

SOAP NOTE : .
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Assessment of current therapy

-

Na+ Na

=
323.4 mEq/L/day
0.9 % NSS 1000 ml V rate 80 ml / hr
24hr 24x80 = 1,920
ml/d
0.9 % NSS 1000 ml Na+ 154 mEq
0.9 % NSS 1,920 ml Na+ = 295.68 mEq
3% NaCl 500 ml V 40 ml / hr x 4hr
4hr 4x40 = 160 ml
3 % NaCl 1000 ml Na+ 514 mEq
3 % NaCl 160 ml Na+ = 82.24 mEq
N a +
2 9 5 . 6 8 + 8 2 . 2 4 = 3 7 7 . 9 2 mEq/L/ d a y

-

K+
Elixir KCl 30 ml Stat (Maximum concentration : 40 mEq/L)
Elixir KCl 15 ml K+ 20 mEq
Elixir KCl 30 ml K+ = 40 mEq
K+ 0.3 mmol/L K+
100 mEq 1 mmol/L K+
100-200 mmol Elixir KCl 30 ml K + = 40
mEq ( K + 0 . 2 6 6 ) M a x i m u m concentration

- hyponatremia
Mixtard Insulin
Premixed insulin
regular +
intermediate Insulin 2
2
7.00. 16.00. 2

RI ( Regular Insulin) I n s u l i n
Short-acting insulin
30-60

RI 6
U SC a c
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NPH (Neutral Protamine Hagedorn Isophane insulin)
Insulin
Intermediate acting insulin
2-4
protamine
NPH 4 U SC


- B1-6-12 1 tab x 3 pc Diabetic
neuropath -



- Ferrous Fumarate 200 mg1 tab x 3 pc



- Folic acid 5 mg 1 tab x 1 pc

Plan: Therapeutic plan

- Mixtard 18-0-8 SC ac
B1-6-12 1 tab x 3 pc
- (FF) Ferrous Fumarate 200 mg 1 tab x 3 pc
- Folic acid 5 mg 1 tab x 1 pc

Goals of treatment

- hyponatremia
-

Therapeutic monitoring parameters

- Biochemistry parameters
Sodium (Na+) [137-145 (mmol/L)]
Calcium (Ca++) [8.4-10.2 (mg/dl)]
Albumin [3.5-5 (g/dl)]

SOAP NOTE : .
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Potassium (K+) [3.5-5.1 (mmol/L)]

Chloride (Cl-) [98-107 (mmol/L)]
Serum ketone [ > 5 (mg/dl) ]
Free T3 [ 2.77-5.27 (pg/ml) ]
- sepsis <180 mg/dl
- < 140/90 mmHg
- Hematology parameters
- Microscopy Urine analysis

Toxic monitoring parameters

- 0.9 % NSS:
Fever, infection at the site of inj, venous thrombosis or phlebitis.
Hypervolemia or hypernatremia.
- 3% NaCl :
Fever, infection at the site of inj, venous thrombosis or phlebitis.
Hypervolemia or hypernatremia.
- Elixir KCl:
GI ulceration (sometimes with hemorrhage and perforation or
with late formation of strictures) following the use of enteric-
coated K chloride preparation; hyperkalemia. Oral: Nausea,
vomiting, diarrhea and abdominal cramps. IV: Pain or phlebitis;
cardiac toxicity.
- Mixtard : Rare incidence of allergy & lipoatrophy,hypoglycemia
- RI: Hypo glycaemia, insulin resistance, lipoatrophy,
hypocalcaemia, blurred vision.
- NPH: Hypoglycemia, lipodystrophy, local & generalized
hypersensitivity reactions.
- Ferrous Fumarate:
GI: Nausea, anorexia, vomiting, constipation or diarrhea,
abdominal cramps, heartburn, black stool.

SOAP NOTE : .
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- Folic acid: GI disturbances, hypersensitivity reactions;

bronchospasm.

Patient education

-
- 5
-

Future plan

- ,

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