CASE PRESENTATION

1. Case on Viral pyrexia,
Antral gastritis and H.Pylori PUD
R.Anusha
Pharm D VI Year
Roll No:170514882007.

2. Patient Name:Ms.SK
Gender:Female
Age:25 years
IP No:297530
DOA:29/2/20
DOD:4/3/20

3. SUBJECTIVE
• Chief Complaints: Fever on and off ,1episode of vomiting
and generalized weakness.
• Present Illness History: Fever on and off ,1 episode of
vomiting and generalized weakness since 1 month.
• Past medical/medication History: Underwent upper GI
endoscopy on 22/2/20 which showed hiatus hernia, Antral
gastritis and H.Pylori +Ve.
• Allergies: NKDA

4. OBJECTIVE
PHYSICAL APPEARANCE:
Patient conscious, oriented
Height: 148cms
Weight: 43 kgs
B.M.I:19 kg/m2.
VITALS:
B.P: 110/70 mm Hg.
R.R: 18 breaths/min.
P.R: 70 beats/min.
CVS:S1S2+
RS:BAE+
P/A:Soft, BS+
Temperature: 99.30 F

5. OUTSIDE LABS on 21/2/20:
Viral screening: - Ve
Sr.Cr:0.64 mg/dl(0.6-1.2)
Urea:17 mg/dl (7-20)
Na+:136 mEq/L(135-145)
K+: 4.1 mEq/L(3.5 – 5.5)
ALP:WNL
SGOT:WNL
SGPT:WNL

6. Diagnostic test:
CBP:WNL
ESR:26 mm/hr(0-20)
Chest X Ray:Normal
USG Abd:NAD
Malarial antigen: -Ve
Dengue NS 1 antigen: -Ve
FINAL DIAGNOSIS: C/o Viral pyrexia, Antral gastritis
K/C/o H.Pylori

7. DRUG CHART
Brand Generic Dose ROA Freq Category Indication
T.ONDEM-MD
29/2/20
Ondansetron
Mouth dissolving
8 mg PO TID Anti emetic Nausea
Inj.PERFALGAN
29/2/20 to 2/3/20
Paracetamol 500 mg IV TID Anti pyretic Fever
SOMPRAZ HP kit
29/2/20
Amoxicillin 1g
Esomeprazole 40 mg
Clarithromycin
500mg
A-1tab
E-1tab
C-1 tab
PO BD
for
14
days
H.Pylori kit H.Pylori
infection
T.LIMCEE
29/2/20
Vitamin C 500 mg PO TID Vitamin C
supplement
H.Pylori
infection

8. SOS/STAT
Brand Generic Dose ROA Freq. Category Indication
T.DOLO Paracetamol 650 mg PO STAT on
2/3/20
Antipyretic Fever
Syp.CITRALKA Disodium
Hydrogen
Citrate
(1.53gm/5ml)
10 ml PO BID on
2/3/20
Urine
alkalizer
Burning
Micturation

9. Goals of the Treatment
• Treatment is aimed at relieving symptoms.
• To eradicate the H.Pylori infection.
• To heal the antral gastritis.
• To improve quality of life.

10. ASSESSMENT
• T.ONDEM MD was given for controlling vomitings.
• Inj.PERFALGAN was given for controlling fever.
• SOMPRAZ HP kit was given for H.Pylori infection.
• Triple therapy consisting of a PPI, Clarithromycin,
Amoxicillin for 10-14 days is a recommended first line
treatment option. Clarithromycin based therapies are
considered to be best tolerated and safest.
• LIMCEE was given for eradicating H.pylori infection.
• Pylori infection is related to low Vitamin C level in the
gastric juice as well as in the serum. Many studies
demonstrated that a high dose of vitamin C would inhibit the
growth and colonization of H.pylori and even eradicate them.

11. • Citralka was given to the patient as she complained burning
micturition on 2/3/20. Citralka Liquid is a urine alkalizer. It
works by increasing the pH of urine which makes it less
acidic.
• Patient improved symptomatically and was hemodynamically
stable at discharge.

12. Patient counselling
Disease related
• Helicobacter pylori infection is a bacterial infection that causes
stomach inflammation(gastritis),peptic ulcer disease, and certain
types of stomach cancer.
• Ulcers may cause no symptoms, or may cause pain or
discomfort , bloating, lack of appetite , nausea, vomiting.
• Foods that stimulate the secretion of gastric juice, such as
coffee, black tea and cola drinks should be avoided during the
treatment of H.pylori as well as foods that irritate the stomach,
such as pepper.

13. Drug related
LIMCEE 500 mg (Ascorbic acid) 1 tab TID PO after food for 10 days.
LESURIDE 25 mg (Levosulpride-Prokinetic) 1 tab TID PO after food
for 2 days.
SOMPRAZ HP kit 3 tabs BD for 10 days(H.Pylori)
Augmentin-AB Augmentin-AD
Esomeprazole-BBF MORNING Esomeprazole-BD EVENING
Clarithromycin-AB Clarithromycin-AD
Two of the medicines are antibiotics that help to kill the bacteria.
The other medication causes the stomach to lower acid levels help the
ulcer to heal.
T.ONDEM MD 8 mg 1 tab PO before food if necessary (Vomiting)
T.DOLO 650 mg 1 tab PO after food if necessary(Fever)