Case Presentation

1. By
BASIL WILSON
13Q0408
PHARM D IVth yr
CASE PRESENTATION ON

2. Definition
Peptic ulcer disease refers to painful
sores or ulcers in the lining of the stomach or
first part of the small intestine, called the
duodenum. An ulcer in the stomach is known
as a gastric ulcer while that in the first part of
the intestines is known as a duodenal ulcer.

3. Etiology
* Helicobacter pylori (H. pylori): a bacteria
that can cause a stomach infection and
inflammation
* frequent use of aspirin, ibuprofen, and
other anti-inflammatory drugs (risk
associated with this behaviour increases in
women and people over the age of 60)
* smoking
* drinking too much alcohol
* radiation therapy
* stomach cancer

4. Peptic ulcers result from an imbalance between factors
that can damage the gastroduodenal mucosal lining and
defense mechanisms that normally limit the injury.
Aggressive factors include gastric juice (including
hydrochloric acid, pepsin, and bile salts refluxed from
the duodenum), H pylori, and NSAIDs. Mucosal
defenses comprise a mucus bicarbonate layer secreted by
surface mucus cells forming a viscous gel over the
gastric mucosa; the integrity of tight junctions between
adjacent epithelial cells, whereby any break in the
epithelial lining is rapidly filled by adjacent epithelial
and mucosal stromal cells migrating and flattening to fill
the gap.
Pathophysiology

5. In duodenal ulcers, chronic H pylori infection
confined mainly to the gastric antrum leads to
impaired secretion of somatostatin and
consequently increased gastrin release, resulting
in gastric acid hyper secretion.
Mucosal defences depend on an adequate blood
supply and on formation within the gastric mucosa.

6. Signs and Symptoms
 changes in appetite
 nausea
 bloody or dark stools
(melena)
 unexplained weight loss
 indigestion
 vomiting
 chest pain
 Burning abdominal pain

7. Demographic Details
Name : ABC Age : 37 Sex : M
I.P No : 27946 Dept. : Medicine Unit : B
D.O.A : 12/08/2016 D.O.D : 16/08/2016

8. Reason For Admission
c/o Abdominal Pain since 5 days
c/o Haematemesis 1 episode
c/o vomiting since 2 days
c/o severe headache
c/o melena 3 episodes
History Of Present Illness
Pt. was app alright 3 months back, then he developed
melena. Pain in abdomen since 5 days, which
was insidious in onset ,progressive in nature
H/o constipation

9. Family History
 Diet : Mixed
 Sleep : Disturbed
 Appetite : Decreased
 Habits : Nil
No Known Allergies

10. Laboratory Data
Hb : 11.8 ↓ (13.5-17.5)
WBC : 11900 ↑ (4500-10500cells/uL)
Lymphocytes : 15 ↓ (20-40%)
Polymorphs : 83 ↑ (40-75%)
RBC : 3.95 ↓ (4.7-6.1 million/uL)
Upper GI Endoscopy : Ulcer in duodenum

11. Provisional Diagnosis :
PEPTIC ULCER DISEASE (PUD)

12. TREATMENT CHART
BRAND NAME GENERIC NAME DOSE ROUTE FREQUENCY DAY
1
DAY
2
DAY
3
DAY
4
DAY
5
Inj.O2 OFLOXACIN +
ORNIDAZOLE
500 MG IV 1-0-1 √ √ √
IVF 2 pint NS
1 pint RL
100ml/
hr
IV √ √
Inj. EMSET ONDANSETRON 4 MG IV 1-0-1 √ √ √
Inj. PAN PANTOPRAZOLE 80 MG IV 1-0-0 √ √ √
40
mg
√
40
mg
√
40
mg
H.PYLORI KIT AMOXYCILLIN +
CLARITHROMYCIN +
LANZOPRAZOLE
1.5 GM P/O 3-0-3 √ √ √ √ √
Syp. CREMAFFIN
PLUS
SODIUJM
PICOSULPHATE +
LIQ. PARAFFIN +
Mg. HYDROXIDE
2 tsp P/O 0-0-1 √ √ √

13. Daily Assesment
Day 1
Afebrile
PR : 100 bpm
B.P : 110/70 mmHg
RR : 18 cpm
Treatment Advice
Inj.O2 IV BD
IVF 2 pint NS 100ml/hr IV
Inj.Pan 80mg IV
H.pylori kit 1 box BD
Inj.Emset 4mg IV
Day 2
Afebrile Continue Same Treatment
Not Fresh Complaints
B.P : 130/80
P.R : 98 bp
R.R : 18 cpm

14. Day 3
No Fresh Complaints Continue Same Treatment
B.P : 140/90 Inj.pan 40 mg
P.R : 82 bpm
Day 4 Treatment Advice
No Fresh Complaints
B.P : 120/80 ADD–Syp.Cremaffin plus 2tsp
P.R : 72 bpm STOP-IVF
Inj. O2
Day 5 Treatment Advice
No Fresh Complaints
B.P : 140/90 STOP-Inj.Emset
P.R : 72bpm

15. FINAL DIAGNOSIS
CHRONIC DUODENAL ULCER
Discharge Medication
BRAND NAME GENERIC NAME DOSE ROUTE FREQUENCY DURATION
Syp.CREMAFFIN
PLUS
LIQ.PARAFFIN+
SODIUM
PICOSULPHATE+
MG HYDROXIDE
2tsp p/o 0-0-1 15 days
T.PAN PANTOPRAZOLE 40 mg P/O 1-0-0 15 days
T,EMSET ONDANSETRON 4 mg p/o s-o-s 15 days

16. PHARMACEUTICAL CARE PLAN
Subjective Evidence
c/o Abdominal pain since 5 days
c/o vomiting 2 episodes
c/o severe headache since today
c/o melena 3 episodes
Objective Evidence
Hb : 11.8 (13.5-17.5)
RBC : 3.95 (4.7-6,1million/uL)
Lymphocytes : 15 (20-40%)
WBC ;11900(4500-10500)
Upper GI Endoscopy : ULCER IN DUODENUM

17. Assesment
Based on the Subjective and Objective evidences ,
it is assesed that the patient is suffering from
CHRONIC DUODENAL ULCER

18. Plan
Treatment Goals
 To reduce abdominal pain
 To stop vomiting
 To reduce headache
 To reduce Melena

20. Standard Recomendations
Peptic ulcers caused due to H. pylori infection
is treated with a course of antibiotics like
amoxicillin and metronidazole.
If it caused by NSAIDs then proton pump
inhibitors like omeprazole and lansoprazole
are prescribed.

22. Patient Councelling
About disease
Peptic ulcer disease refers to painful sores or
ulcers in the lining of the stomach or first part
of the small intestine, called the duodenum.
Common causes include the bacteria
Helicobacter pylori and non-steroidal anti-
inflammatory drugs (NSAIDs).

23. About Drugs
Pantoprazole should be taken 1 hour before
meals.Swallow whole,do not chew/crush.
Amoxicillin may be taken with or without food,may
be taken with meals for better absorption and to
reduce GI discomfort.

24. Life Style Modification
 Avoid indiscriminate use of non-steroidal
anti-inflammatory drugs for pain
 Quit smoking
 Limit intake of alcohol
 Avoid eating outside food from unhygienic
places as H.Pylori is thought to be transmitted
through contaminated food and water
 washing our hands frequently
to avoid infections