Emily is a 67-year-old woman presenting with epigastric pain, nausea, bloating and heartburn for 6 weeks. Physical examination revealed mild epigastric tenderness and stool heme positive. EGD showed a duodenal ulcer and biopsy indicated H. pylori infection. She was diagnosed with H. pylori-associated PUD and prescribed a triple therapy regimen to eradicate H. pylori along with PPI to promote ulcer healing. Her other conditions including CAD, hyperlipidemia, hypothyroidism and overweight were found to be well-controlled with current medical management. Lifestyle modifications and medication adherence were counselled.

1. ADVANCED
THERAPEUTICS
SEMINAR I🩺💊
FINAL PRESENTATION OF
Dr. Maha Adel Rabie
TRAINING INSTRUCTOR
Nada Saud Alotibi
439480726

2. Chief Complaint
“My stomach has been hurting really badly for the past
month or so. It seems to get worse at night.
HPI
Emily is a 67-year-old woman who presents to her primary care
physician with complaints of episodic epigastric pain for the
past 6 weeks. Her pain is nonradiating. It is sometimes eating
helps improve the pain. She has been experiencing occasional
nausea, bloating, and heartburn. She denies any change in
color or frequency of bowel movements. She does not have a
history of PUD or GI bleeding. She mentions that she has been
having frequent headaches for the past month and has been
taking naproxen sodium one to two times daily

3. SH
She is married and has raised three children; she is
not employed outside the home. She has never
smoked and drinks one to two glasses of wine most
days of the week.
Plavix (Clopidogrel)75 mg PO daily
Aspirin 325 mg PO daily
Synthroid( levothyroxine) 125 mcg PO daily
Atorvastatin 80 mg PO daily
MVI tablet PO daily
Tums 500 mg PO PRN stomach pain
Naproxen sodium 220 mg PO PRN headache (one to
two times daily for the past month)
Lactaid one tablet PO PRN dairy product consumption
Meds

4. CAD with drug-eluting stent placement × 3
months
Hypothyroidism × 22 years
Hyperlipidemia × 10 years
Lactose intolerance × 47 years
Postmenopausal; LMP ~13 years ago
PMH
FH
Her mother died at the age of 75 from lymphoma. Her
father is alive and has a history of prostate cancer.
She has five siblings who are alive.

5. All
NKDA
ROS
Unremarkable except for complaints noted above
Physical Examination
Gen
overweight woman in moderate distress
VS
BP 110/72 left arm (seated), P 99, RR 16 reg, T
37.2°C; Wt 68 kg, Ht 5′3′′
Skin
Warm and dry
HEENT
Normocephalic; PERRLA; EOMI
Chest
CTA

6. CV
RRR; S1 and S2 normal; no MRG
Abd
Soft; mild epigastric tenderness; (+) BS; no splenomegaly
or masses; liver size normal
Rect
Nontender; stool heme (+)
Ext
Normal ROM; no cyanosis, clubbing, or edema
Neuro
CN II–XII intact; A & O × 3

7. Labs

8. Normal Labs
Co2 : 23 to 29 milliequivalents per liter (mEq/L)
Retic(reticulocyte count) ranges between 0.5 % to 2.5% in
adults
*The most common causes of low RETIC-HGB are blood loss
and inflammatory disease.
Fe : 60 to 170 micrograms per deciliter (mcg/dL) for women.
Hgb: 11.6 to 15 grams per deciliter for women.
Hct : 36% to 48% normal level for women.

9. Test
Justine’s PCP referred her for a nonemergent
EGD, which revealed a 5.5-mm superficial
ulcer in the superior duodenum. The ulcer base
was clear and without evidence of active
bleeding. In addition, inflammation of the
duodenum was detected and biopsied. At the
time of the EGD, a biopsy of the duodenal
mucosa was taken and indicated the presence
of inflammation and abundant H. pylori–like
organisms

10. PUD / H.pylori
CAD
hyperlipidemia
hypothyroidms
overweight
moderate distress
list of problems
1.
2.
3.
4.
5.
6.

11. My stomach has been hurting really badly for the past month or so. It
seems to get worse at night.
episodic epigastric pain for the past 6 weeks , no radiating pain, the pain
deceased with eat
nausea, bloating, and heartburn, headache
inadequate symptom relief with TUMS
Tums 500 mg PO PRN stomach pain
Naproxen sodium 220 mg PO PRN headache (one to two times daily for
the past month)
Drinks one to two glasses of wine most days of the week.
PUD / H.pylori
S:
O:
PE Significant for:
• woman in moderate distress, P99
•Mild epigastric tenderness
•Stool heme(+)
• Labs significant for: Low Hgb, Low Hct,Biopsy indicated the presence of
inflammation and abundant H. pylori–like organisms

12. PUD / H.pylori
A: patient is diagnosed with suspected PUD , she have many risk factor : older than
60 years old , drinking alcohol , use non selective NSAID ( Naproxen sodium)
She requires immediate intervention to control symptoms, eradicate H. pylori, and
heal the suspected ulcer.
P: Goals of Therapy
•Eradicate H. pylori
•Promote ulcer healing
•Relieve pain and discomfort associated with PUD
•Prevent complications of PUD
•Prevent ulcer recurrences

13. PUD / H.pylori
Drug Therapy Recommendations
•Initiate triple therapy for eradication of H. pylori
oPPI once or twice daily (like omeprazole, lansoprazole,pantoprazole)
oClarithromycin 500 mg PO twice daily
o amoxicillin 1g PO twice daily
Oral Drug Regimens Used to Heal Peptic Ulcers and
Maintain Ulcer Healing

14. PUD / H.pylori
Continue PPI for at least 6 weeks after eradication regimen to ensure healing of
ulcer
Option:
Probiotics (such as strains of Lactobacillus and Bifidobacterium) and foods (such as
cranberry juice and some milk proteins) with bioactive components have been used
proactively to control H. pylori colonization in at-risk individuals and, when taken
as a supplement to eradication therapy, may have a role in improving H. pylori
eradication and reducing the negative effects of PPI-based triple therapy.
decases aspirin (it class is NSAID which it worse the patient condition) to 81 mg orally
daily ( as guideline dosage)
or
Discontinue use of Aspirin (it class is NSAID which it worse the patient condition ) and
our patient has CAD and according to <2021 ACC/AHA/SCAI Guideline for Coronary
Artery> Discontinuation of aspirin after 1-3 mo with continued P2Y12 monotherapy
Because patient has done DES and has risk of bleeding.Clopidogrel75 mg PO daily

15. PUD / H.pylori
Encourage lifestyle modifications
Avoidance of foods that can aggravate ulcer (e.g. spicy food, chocolate, acidic
foods)
Avoidance of alcohol
Avoidance of medications with potential to cause GI toxicity (if possible)
Resolution of symptoms (e.g. epigastric pain, normalization of Hgb/Hct)
Negative H. pylori upon testing
No recurrence of ulcer
Nonpharmacologic Recommendations:
Monitoring Parameters:
Efficacy:

16. PUD / H.pylori
Safety:
o PPIs: headache, GI upset, low vitamin B12, fractures (d/t reduced calcium
absorption)
o Clarithromycin: headaches, GI upset, taste disorder, LFT changes, prolonged QT
interval
o Amoxicillin: skin rash; itching; shortness of breath; trouble with breathing; trouble
with swallowing; or any swelling of your hands, face, mouth
Clinical Teaching:
•General info related to PUD:
o Discontinue use of NSAIDs (e.g., ibuprofen, naproxen, or ketoprofen); use
acetaminophen if you need something for pain.
o Avoid or limit ingestion of foods and liquids that aggravate your abdominal pain.

17. PUD / H.pylori
PPIs:
oWarn patient to report diarrhea that does not improve, especially with persistent
watery stools, fever, and abdominal pain
oWarn patient to immediately report signs/symptoms of hypomagnesemia, including
palpitations, dizziness, seizures, or involuntary muscle contractions
oAdvise patient to take drug at least 1 hour before a meal
Clarithromycin:
oAdvise patient to immediately report signs/symptoms of hepatotoxicity or
Clostridium difficile-associated diarrhea (severe, watery, or bloody diarrhea).
oEncourage patient to complete full course of therapy
amoxicillin:
oEncourage patient to complete full course of therapy
Plan for F/U:
•Patient should be seen by PCP after eradication regimen for reassessment

18. CAD
Option:
S: none
O: CAD with drug-eluting stent placement × 3 ,TC 142 mg/ dL , LDL 64 mg/dL , HDL 53
mg/dL , TG 127 mg/dL
A :Patient with has CAD currently well controlled
P: Goals: LDL <100 mg/dL,HDL > 50 mg/dL,TG < 150 mg/dL , BP <130/80 mmhg
Prevent atherosclerosis and IHD
Improve morbidity and mortality
Recommendations:
decases aspirin to 81 mg orally daily (guideline dosage) and continue clopidogrel as
same regimen
or
Discontinue use of Aspirin (it class is NSAID which it worse the patient condition ) and
our patient has CAD and according to <2021 ACC/AHA/SCAI Guideline for Coronary
Artery> Discontinuation of aspirin after 1-3 mo with continued P2Y12 monotherapy
Because patient has done DES and has risk of bleeding.Clopidogrel 75 mg PO daily

19. CAD
Non pharmacological
-modifying lifestyle
-do sports that not hard
-eatbalance food
-no smoking, discountone alcohol
Monitoring Parameters:
Efficacy – Platelet Aggregation(clopidergral,aspirin)Lipid
panel , BP , o2 level
Safety – Bronchospasm(aspirin), GI upset,
rash(clopidergral),clotting , bleeding(aspirin), Gastrointestinal
ulcer(aspirin),

20. CAD
CLINICAL TECHING:
Don't be nervous and take it easy
Reinforce the importance of notifying doctor whenever angina pain is experienced.
Walk or do some form of physically activity on most days of the week.
Take with a full glass of water and take at the same time each day
Do not take 2 hours before or 1 hour after consuming alcohol
follow up
Maintain continuous ECG monitoring, monitor for arrhythmias and ST elevation ,BP
heart rate , blood monitoring, blood flow , Platelet Aggregation

21. Hyperlipdemia
S: none
O: TC 142 mg/ dL , LDL 64 mg/dL , HDL 53 mg/dL , TG 127 mg/dL, history of
hyperlipidemia
A :Patient with hyperlipidemia currently well controlled on atorvastatin
P: Goals: LDL <100 mg/dL,HDL > 50 mg/dL,TG < 150 mg/dL
Prevent atherosclerosis and IHD
Improve morbidity and mortality
Recommendations:
Continue atorvastatin 10 mg PO daily
Nonpharmacologic Recommendations:
eat healthy food with less lipid , do sport
Monitoring Parameters:
Efficacy – Lipid panel
Safety – LFT’s, myalgia, CPK (if muscle pain, weakness), dark urine, GI upset,
rash

22. Hypothryoidism
S: None
O: history of hypothyroidism
Levothyroxine(synthroid) 125 mcg po daily
TSH 2.4 microU/L
A: Ema is a 67-year-old woman with a history of hypothyroidism that appears to be
well-managed with levothyroxine at her current dose.
P: Goals of Therapy:
Alleviate the clinical signs and symptoms of hypothyroidism.
Normalize thyroid laboratory tests and maintain long-term control.
Assure adherence with the pharmacotherapy regimen.

23. Hypothryoidism
Drug Therapy Recommendations:
Continue levothyroxine 125 mcg po daily
Nonpharmacologic Recommendations:
Iodine rich diet like fish ,milk , eggs
Monitoring Parameters:
Efficacy:
Alleviation of symptoms
Adherence to therapy
Monitor TSH every 6 to 12 months
Safety:
Levothyroxine: s/sx hypo- or hyperthyroidism

24. Hypothryoidism
The reason for taking this medication is to replace the
hormone that your thyroid gland is not producing in
adequate amounts.
Take this medication once a day exactly as your doctor
directed.
Space this medicine from your iron and calcium tablets by
at least 3–4 hours. The iron and calcium tablets may reduce
the amount of thyroid hormone your body will absorb.
Clinical Teaching:

25. Overweight & moderate distress
Increase fluid intake, relaxation, quiet music, quiet,
exercise during the day, eliminating caffeine-sleep hygiene,
find a hobby
S:none
o: height, weight , body index
a: according to physical examination by doctor that our
patient have overweight and distress
P: goal:1-reduce weight 2-relief stress
Treatment recommendations;
Non pharmacological treatment :(prefers)
follow up: see the doctor after 4 week