Duodenal ulcer- Soap analysis

1. CASE PRESENTATION ON
DUEODENAL ULCER BY
SOAPANALYSIS
Zainabath Mahnoora
NU20PHPP13
1st M Pharm, Pharmacy Practice

2. PROBLEM LIST:
Duodenal ulcer
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3. I. PATIENT DEMOGRAPHIC DETAILS:
 Hosp. No: 19046630
 Name: S.S
 Age: 21yrs
 Gender: Male
 Height: 189cm
 Weight: 85kg
 Date of admission: 12/1/2021
 Date of discharge: 18/1/2021
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4. II. SUBJECTIVE EVIDENCE:
 Chief complaints:
• Pain in abdomen for 15 days
• Episodes of haemtemesis for 1 day
• Giddiness with Cough

5. III. OBJECTIVE EVIDENCES:
 Medical history: NAD
 Medication history: NAD
 Social history: Mixed diet; appetite – irregular; adequate sleep
 Family history: NIL
 Personal history: Person was skipping meals for college
 Previous allergies: Not known allergies

6.  Physical examination:
 GENERAL -- Conscious; well oriented; moderately built; NO PICCLE
 VITAL SIGNS -- PR:86BPM; BP:110/70mmhg; SPO2: 2.99%
 Systemic examinations:
 RS -- NVBS blind; no added sound
 GIT -- NORMAL shape; umbilicus central and inverted; all quadrants move equally with
respiration; no local rise in temp; tenderness in umbilical region resonant note heard in all region
 PROVISIONAL DIAGNOSIS: Haematemesis

7. Routine biochemical examinations:
 T Bilirubin: 1.78mg/dl ( 0.2 - 1.2mg/dl)
 D Bilirubin: 0.44mg/dl ( 0.0 - 0.4mg/dl)
 Prothrombin time: 15.5s ( 11 – 13.5s )
Others:
 Endoscopy: shown ulcerated lesions above the duodenal region and confirmed as duodenal ulcer
Duodenal ulcer seen at endoscopy

8. IV. ASSESSMENT:
 Final diagnosis: Based on subjective and objective evidences, patient is found to
be having DUODENAL ULCER

9.  Etiology:
Is unknown
 Risk factors:
 Gender - male
Skipping meals
Irregular appetite

10.  Is therapy indicated ?
Yes therapy is clearly indicated because
 Clear proof of complication is obtained by diagnostic method- DUODENAL ULCER
 For treating the complications
 Relieving the symptoms such as abdominal pain, haemtemesis and giddiness.

11. Current therapy:
SL.NO GENERIC NAME BRAND NAME DOSE ROUTE FREQUENCY DURATION
1. RINGER LACTATE RL 100ml IV AN HOUR D1
2. PANTAPRAZOLE Inj. PANTOP 40mg IV 1-0-1 D1 - D6
3. ONDANSETRON Inj. EMESET 4mg IV S O S D1 - D6
4. TRAMADOL Inj. TRAMAZAC 50mg IV S O S D1 – D6
5. SUCRALFATE Syp. SUCRAL 30ml ORAL 1-1-1-1 D1 - D6
6. PANTAPRAZOLE Tab. PANTOP 40mg ORAL 1-0-0 D1 – D6
7. MAGNESIUM
HYDROXIDE
Syp. CREMAFFIN 10ml ORAL HS D1 – D6

12. ASSESSMENT OF CURRENT THERAPY

13. 1. Inj. RL (100ml/hour) D1
Generic name : Ringers lactate (combination of Nacl, Na lactate, K chloride, Ca chloride)
Class : TPN (total parenteral nutrition)
MOA : For resuscitation from blood loss, produces metabolic alkalinizing effect.
Indication : Fluid and electrolyte balance
ADR : Fever, infection at site of injection, hyperkalemia
Justification : According to INTERNATIONAL JOURNAL OF CONTEMPORARY MEDICAL
RESEARCH 2017, RL is found to be superior to NS for fluid resuscitation because NS has vasodilator effect with
an increase in serum potassium level and risk of metabolic acidosis.
 Since the patient is not diagnosed with hyperkalemia and hypocalcaemia RL is safe to use.
 It has severe -contraindication with ceftriaxone, nitroglycerin, propanol etc. Hence not with any drugs
prescribed here
 There is not any known case of hypersensitivity, which makes safe use of ringers lactate

14. 2. Inj. Pantop (40mg)(1-0-1) D1 – D6
Generic name : Pantoprazole
Class : Proton pump inhibitor
Dose : loading dose of 80mg, followed by 40mg/day. Max dose of 240mg/day in divided dose
MOA : Suppresses gastric acid secretion by inhibiting the parietal cell H+/K+ ATP pump
Indication : To treat and prevent duodenal ulcer complications. Prevent persistent cough.
ADR : Headache, diarrhea
Justification : According to AMERICAN JOURNAL OF GASTROENTEROGY,2020; Pantoprazole is
more effective than ranitidine in the treatment of duodenal ulcer providing faster healing with rare adverse effects.
 According to AMERICAN JOURNAL OF HEALTH - SYSTEM PHARMACY,2021; Pantoprazole is well
absorbed, undergoes little first – pass metabolism, and has an absolute bioavailability of approx. 77%. It has
undergone 100 clinical trials with 11,000 patients for proving the effectiveness in treatment of duodenal and
gastric ulcers

15. 3. Inj. Emeset (4mg)(SOS) D1-D6
Generic name : Ondansetron
Class : Antiemetic
Dose : 4 – 8mg every 8 hours, Maximum of 16mg per dose
MOA : Works by blocking the release of the chemical serotonin in the gut and the CNS. This keeps
serotonin from causing nausea and vomiting
Indication : Prevention of nausea and vomiting
ADR : Headache(within min of administration), hypersensitivity reactions (urticaria, angioedema)
Justification : It appears in the WHO’s list of essential medicines, which is the list of medications that are
most effective and safe in meeting the important needs of health system.
 It is 1 of 4 FDA approved serotonin receptor antagonists used to combat nausea and vomiting, they act both
centrally and peripherally to prevent nausea and vomiting.
 According to this standard 4mg iv and 8mg oral every 12 hours, 16mg not recommended by the FDA.

16. 4. Inj. Tramazac (50mg) (SOS) D1-D6
Generic name : Tramadol
Class : Analgesic
Dose : 50mg/ml or 100mg/ml 4-6 hourly, up to total daily dose limit – 400mg
MOA : Binds to opiate receptors in the CNS causing inhibition of ascending pain pathways
Indication : Treatment of moderate to severe pain
ADR : Dizziness(14.9%), nausea(24.1%), dry mouth, drowsiness, headache, sedated state
Justification : According to FDA Drug Safety Communication, 2017; the drug is relatively safe for children ages
above 17 with right dose and frequency.
 Tramadol is used worldwide and is listed in Guidelines for treatment of pain
 Advisory Council on Misuse of drugs (ACMD),2017; recommended tramadol is controlled as class C substance
 According to FDA can be used for moderate and moderately - severe pain in adults, max dose of 400mg and start with
25mg and daily dose of 50mg for 3 days.

17. 5. Syp. Sucral (30ml) (1-1-1-1) D1-D6
Generic name : Sucralfate
Class : Gastrointestinal agent, protectants
Dose : 30 TO 80mg/kg/day divided every 6 hour, Max dose- 1000mg/dose
MOA : It sticks to damaged ulcer tissue and protects against acid and enzymes healing can occur,
It absorb bile acid
Indication : Treatment of active duodenal ulcer
ADR : Constipation, hives, rashes, itching, dyspnea
Justification : Sucralfate is FDA approved for short – term (8weeks) treatment of duodenal ulcers.
 According to NATONAL LIBRARY OF MEDICINE it is a unique anti-ulcer drug with favorable safety and
efficacy
 Has less side effect compared to any drug of this category, because it is not much absorbed (3-5%), more than 90% is
excreted unchanged in faecus

18. 6. Tab. Pantop (40mg) (1-0-0) D1-D6
Generic name : Pantoprazole. tab
Class : Proton pump inhibitor
Dose : loading dose of 80mg, followed by 40mg/day. Max dose of 240mg/day in divided dose
Has to be taken 30min prior to food, don’t crush or chew the tab-just swallow
MOA : Suppresses gastric acid secretion by inhibiting the parietal cell H+/K+ ATP pump
Indication : To treat and prevent duodenal ulcer complications. Prevent persistent cough.
ADR : Allergic reactions, headache, diarrhea
Justification : According to AMERICAN JOURNAL OF GASTROENTEROGY,2020; Pantoprazole
is more effective than ranitidine in the treatment of duodenal ulcer providing faster healing with rare adverse
effects.
 It is the first FDA approved PPI available both has oral and iv formulation, for short term treatment up to
16 weeks

19. 7. Syp Cremaffin (10ml) (HS) D1-D6
Generic name : Magnesium hydroxide
Class : Antacid; laxative
Dose : 800mg/5ml: 15 to 30ml/day once at bed time, Max dose of 60ml in 24 hours
MOA : Promotes bowel evacuation by causing osmotic retention of fluid which distends the colon
with increased peristaltic activity, reacts with HCl to form Mgcl
Indication : ANTACID: For temporary relief of heartburn, upset stomach
LAXATIVE: Relief of constipation
ADR : Loose, watery or more frequent stools, headache, nausea
Justification : It is an FDA approved drug for treatment with dose of 20mg for 4 weeks in adult patient of
18yrs and older.
 It is an FDA approved antacid for treatment of acidity and laxative action with dose of 2-4 tsp with 8 ounce
of liquid, 4 times daily and not more than 12 tsp in 24 hrs and not max dose for more than 2 weeks

20. PLANNING OF THERAPY

21.  TREATMENT RELATED GOALS:
 Overall goal is to reduce morbidity and mortality
 Prevention of recurrence and progression of complication such as abdominal pain and hematemesis
 To improve the quality of life
 PATIENT RELATED GOALS
 To treat duodenal ulcer
 To restore normal GIT function
 To prevent hematemesis
 To reduce abdominal pain
 To restore health
GOALS OF THERAPY

22. MONITORING PARAMETERES
 Therapeutic monitoring:
 Endoscopy for wound healing
 Stool analysis for pylori infection
 ECG only if there is any associated symptoms of palpitation or seizures- onansetron
 PT and INR monitoring- Tramadol increase
 Toxicity monitoring:
 Magnesium and potassium toxicity - Ondansetron
 Drug withdrawal symptom for tramadol
 Hypersensitivity reactions of magnesium hydroxide

23.  POINTS TO PHYSICIAN
 Appetite enhancers can be given to regulate proper food habits of the patient such as Oxandrolone or
megaestrol acetate, the drugs that FDA have approved as appetite stimulants
 PATIENT DUCATION
 About the disease
You are suffering from duodenal ulcer which is formation of sores in the lining of intestinal duodenum- first
part of intestine, this is because of your habit of skipping meals, the gastric juice attack its own tissues forming
sores. Since it is found without much complications it was managed, further delay in treatment could bring
severe complications.
 About medication
• Ringer lactate- for correcting physiological disorder-blood loss
• Pantoprazole – suppress gastric acid secretion
• Ondansetron – for vomiting and nausea- take only if needed

24.  Tramadol – pain killer for abdominal pain
 Sucralfate – protectant for the sore from further attack and healing
 To be taken 30 min prior to antacid
 Magnesium hydroxide – for easy movement of stool
 This drug has to be taken 2 hour before or after taking any other medication
 If you miss your dose, take it soon as possible if the duration of next drug is at least 4 hours apart
 If it is near to next dose, skip the dose and continue the next dose at usual time, do not overdose.
 Consult your physician for any severe side effects
 Inform your doctor when any new otc drug, herbal or any vitamin supplement is taken
 DISCHARGE MEDICATION
Drug Dose Frequency Duration
Syp. Sucral 30ml 1-1-1 14 days
Tab. Pantoprazole 10mg 1-0-0 14 days
Syp. Cremaffin 10ml HF 14 days

25. LIFESTYLE MODIFICATION
 NEVER EVER SKIP YOUR MEAL WITHOUT ANY VALID REASON
 Maintain healthy lifestyle
 Eat diet rich in fiber, especially fruits such as apple, banana and vegetables such as carrot, green piece,
cabbage, beetroot and cauliflower
 Take fermented foods such as yogurt
 Anti- oxidant drink such as green tea is best
 Leafy greens and sprouts – increased intake
 Use plant based oil such as olive oil
 Limit intake of caffeine, chocolates, fatty foods and spicy foods
 Avoid intake of acidic foods such as citrus fruits- oranges and tomatoes
 Avoid over-eating before bed
 Honey, garlic, turmeric, ginger and whole grain have good ulcer protective activity
 Formulated food- probiotics such as cheese, pickles and bread

26. FOLLOW UP
Review after 2 weeks in surgery 3 OPD