This case study presents a 3-year old female patient admitted with fever, coffee ground vomiting and abdominal pain. She had a history of upper respiratory infection and allergy to cephalosporin and amoxicillin. Endoscopy revealed a non-bleeding gastric ulcer. Laboratory tests showed signs of anemia and inflammation. She was diagnosed with NSAIDs-induced peptic ulcer disease. Her treatment plan included cefotaxime, paracetamol, esomeprazole, and pantoprazole. She was discharged after 2 days with counseling on diet, medication use, and follow up.

1. Case study on peptic
ulcer disease
PRESENTED BY KRISHNA M 4TH PHARM D

2. SUBJECTIVE
A 3 – year old female patient was admitted with fever , coffee , ground vomiting and abdominal ,
Hemodynamically stable .

3. HISTORY OF PRESENT ILLNESS
H/O fever +
H/O coffee ground vomiting
H/O abdominal pain
H/O general malaise
H/O dehydration

4. PAST MEDICAL AND MEDICINE HISTORY
H/O upper respiratory infection
H/O allergy to cephalosporin , amoxicillin / clavulanic
DRUG CHART ( UPPER RESPIRATORY INFECTION )
IBUPROFEN 100MG
CLARITHROMYCIN 7.5MG/KG/DAY

5. FAMILY HISTORY
H/O PEPTIC ULCER

6. GENERAL EXAMINATION
Conscious oriented
BP 108/71
•Pulse 128
•Alert
•active
• playful
no clubbing
no lymphadenopathy

7. SYSTEMIC EXAMINATION
CVS –S1S2+
RS- BAE+
CNS- NFND
P/A- Soft
ENDOSCOPY : non bleeding gastric ulceration

8. LABORATORY INVESTIGATION

9. PARAMETERS OBSERVED VALUE REFERENCE VALUE
Haemoglobin 10.5g/dl 11.3-14.1g/dl
ESR 25mm/hr Upto 20mm/hr
HCT 28.1% 30-39%
RBC 3.95 million/mm³ 3.80- 5.20 million/mm³
Total WBC 20,000cells/cu.mm 6000-17,500 cells/cu.mm
Lymphocytes 12.3×109/l 1.0–13.5×109/l
Monocytes 1.5×109/l 0.1–1.5×109/l
Granulocytes 8.2x109/l 1.0–8.5×109/l
Lymphocytes 53.4% 47-77%
Monocytes 6.8% 2-10%
Granulocytes 39.8% 15-45%
Platelet 499,000/mm³ 150,000-450,000/mm³
MCV 75.2fl 77-108fl
MCH 26.0pg /cell 27-35pg/cell
MCHC 35.5g/dl 32-36g/dl

10. Blood sugar
RBS 82mg/dl 80-140mg/dl
RENAL PROFILE
Blood Urea 30mg/dl 10-50mg/dl
Serum Creatinine 1.0mg/dl 0.6-1.9mg/dl
URINE ANALYSIS
Colour Pale yellow
PH Acidic
Albumin Nil
RBC Nil
Sugar Nil
Puss cells 2-4HPF 5-10HPF
Epithelial cells 0-1/HPF 5-10/HPF
Cast crystals Nil
RA factor Negative
CRP Negative

11. FINAL ASSESSMENT
DIAGNOSIS
NSAIDS INDUCED PEPTIC ULCER DISEASE

12. TREATMENT PLAN

13. GOALS OF THEARPY
An intestinal infection marked by diarrhoea , cramps, nausea, vomiting and fever.
The goals of pharmacotherapy are to reduce morbidity, prevent complications, and provide
prophylaxis.
Probiotics are live microbial feeding supplements commonly used in the treatment and
prevention of acute diarrhea.
zinc supplementation may be effective in reducing the duration of diarrhea in children older than
6 months.

14. DRUG CHART

15. BRAND NAME GENERIC
NAME
DOSE ROUTE FRQ 1 2
Inj.Taxim Cefotaxime 250mg i.v 8th
hourly

t. dolo paracetamol 250 mg oral od 
t. esomeprazole esomeprazole 10mg / day oral od  

16. DRUG SUMMARY
Patient Discharge After 2 days of Adminisation
Pantoprazole
No drug drug intraction

17. DRUG DRUG INTRACTION
NO INTRACTION HAS BEEN FOUND

18. PATIENT COUNSELLING

19. DISEASED BASED COUNCELLING
Disease completely cured once patient complete drug plan completely .
IF any vomiting persist parents should immediately contact the doctor and stop the medication.
Give diet like protein , carbohydrate rich food in order to prevent dehydration.

20. DIET COUNSELLING
PATIENT SHOULD AVIOD SPICY FOODS .
PATIENT SHOULD NOT TAKE LARGE AMOUNT OF FOOD.

21. DURG BASED COUNSELLING
FOLLOW UP THE PRESCRICTION IN ORDER AVIOD PAIN , DISCOMFORT ETC..
ANY ADVERSE REACTION IMMEDIATELY STOP THE MEDICATION , IN ORDER TO PREVENT THE
TOXIC EFFECT .