a case study on peptic ulcer

case study on peptic ulcer , this describes all the aspects of treatment , diagnosis, management & patient counselling etc
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1. CASE STUDY ON PEPTIC ULCER By , MARTIN SHAJI , Pharm-D

2. PATIENT DETAILS:- Patient Name: Mrs.X Age/Gender: 60Y/F Admission No (OP/IP): 24518 Department : Female general medicine Ward/Unit: FMW-III Date of Admission: 20/9/17 Date of Discharge: 24/9/17.

3. Chief Complaints: epigastria pain, burning sensation in the abdomen with fever since 4 days History of present illness: nil significant Past medical History: (Diseases, Disorders, Surgeries, Medicines used) Not a known HTN/DM/TB Allergies (food/drug/other): Not a known allergic

4. ON EXAMINATION General Examination: patient was conscious and co-operative Physical examination: Temperature ( o F ): 102 Pulse rate (b/min): 72 Respiratory Rate (cycle/min ): 22 Blood Pressure (mm of Hg): 100/70   2. Systems Examination: CVS: S 1 S 2 + RS: clear CNS: NAD

5. RADIOGRAPHIC DATE: Endoscopy revealed positive for peptic ulcer CONFORMATORY DIAGNOSIS: PEPTIC ULCER

6. DRUG CHART SLNO BRAND NAME GENERIC NAME INDICATION DOSE ROA FREQ DAYS OF TMT 1. Inj.Rantac Ranitidine Anti-ulcerative 40mg IV BD 4 DAYS 2. Cap.omeprazole omeprazole Anti-ulcerative 20mg P/O OD 4 DAYS 3. Tab.PCT Paracetamol Anti-pyretic 500mg P/O TID 4 DAYS 4. Inj. Dicycloverine Dicycloverine hydrochloride Anti-spasmodic 2mg IM TID 4 DAYS 5. IVF Intravenous fluids Electrolyte replenisher 1unit IV OD 4 DAYS

7. Discharge medication: R x T.Rantac 150mg Bd Cap.Omeprazole 20mg OD Tab.Paracetamol 500mg TID Tab.Dicycloverine HCl BD Review after one week...  

8. I. Soap Notes: 1. SUBJECTIVE EVALUATION: A female patient of age 60 years was admitted in female general medicine o unit-III with complaining of epigastria pain, burning sensation in abdomen. 2. OBJECTIVE EVALUATION: On general examination patient was conscious and cooperative. The patient’s body shows rise in temperature of 102 F. 3. ASSESMENT: Based on subjective and objective evidences the patient was diagnosed as PEPTIC ULCER . Anti- ulceratives can be assessed to the patient.

9. 4. PLANNING: The patient was diagnosed as peptic ulcer. On day of admission Inj . Rantac 2cc IV BD was given to the patient and it is an anti-ulcerative and is an H 2 receptor antagonist and is used for reducing the stress ulceration of upper GT tract. T. PCT was given with a dose of 500mg thrice in a day. It acts as antipyretic and analgesic and it is used to reduce fever and body pains. Cap.Omeprazole with a dose of 20 mg was given once in a day which acts as anti- ulverative and relieves burning sensation. Inj. Dicycloverine HCl was given intramuscularly thrice in a day and it acts as antispasmodic. Same treatment was continued for four days

10. II.PHARMACEUTICAL CARE ISSUES (ADR, DDI , Rationality, Patient intervention etc.): No ADR &DDI were found so given prescription was appropriate.

11. III.PATIENT COUNSELLING: 1. Regarding disease & medication : Abdominal pain, heartburn belching bloating, abdominal fullness, cramping are the symptoms. Lack of uniformity of mucous membrane due to destruction of cells because of excessive production/secretion of acid by the gastric cells. T.RANTAC (Ranitidine): It is an anti ulcer drug. It has to be taken 30 mins after taking food. It prevent gastric ulcerations due to the other drugs and should be taken one in the morning and another in the night. T.PARA ( Paracetamol ): It is used to relieve pain, take once in the morning and once at night after food. It can cause rashes and GI upsets. One tablet should be taken in the morning and one in the night after food. Cap.Omeprazole : it acts as anti-ulcerative and it should be taken once in the morning and has to be taken 30 mins before taking food. Tab. Dicycloverine HCL: it is anti-spasmodic drug and should be taken once in a day.

12. 2. Regarding Life-style & modification: Advice to avoid junk food, spicy food & fatty food Avoid smoking & alcohol intake Avoid intake of large meals, chocolates and tight clothing, belts Advice not to take drugs which may cause lower esophageal sphincter pressure like diazepam, nifedipine , theophylline etc Take food in correct time Avoid stress. Maximum use of NSAIDS should be avoid, if necessary take any alternative therapy Do not use belts in case of surgery

13. DISCUSSION : Peptic ulcer disease refers to a group of ulcerative disorders of the upper gastrointestinal (GI) tract that require acid and pepsin for their formation. Ulcers differ from gastritis and erosions in that they extend deeper into the musularis mucosa. The three common forms of peptic ulcers include Helicobacter pylori (HP)-associated ulcers, nonsteroidal anti-inflammatory drug (NSAID)-induced ulcers, and stress-related mucosal damage (also called stress ulcers). Symptoms: Abdominal pain Heartburn Belching Bloating vagus discomfort abdominal fullness Cramping

14. THAN Q