Case Study (peptic Ulcer) 3e3i4m

GROUP 7 Pamintuan, Adie Kim Quetua, sca Marie Robles, Ma. Cecilia Santos, Amalia Tapaoan, Symphony Jane

CASE 1 (FINALS)

CHIEF COMPLAINT “My stomach has been hurting for the past weeks. Over the weekend I noticed my bowel movements were black and tarry.”

PATIENT DEMOGRAPHICS William Smith Male 62 years old Height: 5’9’’ Weight: 102kg

HISTORY OF PRESENT ILLNESS Intermittent burning epigastric pain for more than 2 months. Intermittent belching, bloated, weak when walking and nausea after eating. Pain in right epigastrium, worse with meals.

HISTORY OF PRESENT ILLNESS  Black, tarry bowel movements  No PUD or GI bleeding  No anorexia or vomiting

PAST MEDICAL HISTORY  COPD (Chronic Obstructive Pulmonary Disease) x 10 years  DM (Diabetes Mellitus) x 10 years  Osteoarthritis x 15 years (right shoulder)

FAMILY HISTORY

 Father died at 55: Acute Myocardial Infarction (MI)  Mother died at 65: Lung Cancer (CA)  3 siblings alive and well

SOCIAL HISTORY  ant  Married and has 3 daughters  Smokes cigar occasionally  Drinks beer per week

REVIEW OF SYSTEMS  Unremarkable except for complaints noted above

ALLERGY: Penicillins – hives PHYSICAL EXAMINATION: General Overweight man in moderate distress SKIN: Warm and dry HEENT: PERRLA, EOMI, discs flat, no AV nicking, hemorrhages, or exudates CHEST: Bilateral rhonchi, faint wheezes

REVIEW OF SYSTEMS CARDIOVASCULAR: S1, S2 normal; no MRG ABDOMEN: Normal bowel sounds and mild epigastric tenderness; liver size normal; no splenomegaly or masses observed RECTAL: Nontender,; melenic stool found in rectal vault; stool heme (+) EXTENSION: Normal ROM except for restricted right shoulder movement NEURO: CN II-XII intact, DTRs 2 + throughout

VITAL SIGNS  BLOOD PRESSURE: 120/62  PULSE: 109  RESPIRATORY RATE:18  TEMPERATURE:37.9

LABORATORY RESULTS RESULTS  SODIUM 144 meq/l  HEMOGLOBIN 9.2 g/dl  CALCIUM 9.2 mg/dl  POTASSIUM 3.9 meq/l  HEMATOCRIT 26.2%  MAGNESIUM 2.0 meq/l

REMARKS X √ X X √ √

LABORATORY RESULTS RESULTS  CHLORIDE 98 meq/l  IRON 49 mcg/dl  PHOSPHORUS 4.0mg/dl  CARBON DIOXIDE

REMARKS X √ X √

LABORATORY RESULTS RESULTS

REMARKS

ALBUMIN 3.9 g/dL

X

BLOOD UREA NITROGEN 10 mg/dL

X

FASTING BLOOD GLUCOSE 154 mg/dL

√

MEAN CORPUSCULAR VOL 74 mm3

√

PLATELET 230 X 103 /mm3 RETICULOCYTES 0.3% SERUM CREATININE 1.1 mg/dL WHITE BLOOD CELLS 8.4 x 103/mm3

X √ X X

DIAGNOSTIC PROCEDURES  Endoscopy 6-mm ulcer in the gastric antrum  Peripheral Blood Smear (+) for Microcytic anemia

ABBREVIATIONS  PUD – Peptic Ulcer Disease  GI – Gastrointestinal  PERRLA -Pupils Equal, Round, Reactive to Light and Accommodation  EOMI –Extra ocular Movements Intact  AV – Atriovenous  ROM – Range of Motion  CN – Cranial Nerve  DTR – Deep Tendon Reflex

MEDICATIONS DRUGS METFORMIN (Glucophage®)

MOA

INDICATION

Reduce hepatic glucose through activation of AMPK

Type II Diabetes

Lactic acidosis, CHF, hypoxic/acidotic states

Irreversible inactivation of the cyclooxygenase (COX) enzyme

Reduce fever and relieve mild to moderate pain from conditions such as muscle aches

Stomach upset, heartburn

Short acting muscarinic antagonist

Long-term treatment of reversible bronchospasm associated with COPD

urinary tract infection, upper respiratory tract infection, sinusitis, bronchitis, and exacerbation of COPD

500mg PO BID ASA (Aspirin EC®) 325mg PO once daily IPRATROPIUM MDI (Atrovent®) 2 puffs 4x daily

ADR

MEDICATIONS DRUG ALBUTEROL MDI (Ventolin®) 2 puffs PRN IBUPROFEN (Advil®)

MOA

INDICATION

Short-acting, selective B2adrenergic receptor agonist

Asthma and COPD

Acute infection of the nose, throat, sinus, fast heartbeat, feeling of throwing up

Related to (NSAIDs), prostaglandin synthetase inhibition

Used to reduce fever and treat pain or inflammation

Hemorrhage, vomiting, hypertension, eosinophilia, and anemia

Neutralizes gastric pH

Heartburn, acid indigestion, sour stomach, upset stomach

Nausea, constipation, diarrhea, headache

200mg 2 tabs PRN Mg Hydroxide, Al Hydroxide (Maalox®) 1 tbsp. PRN

ADR

DRUG INTERACTION  Alcohol & metformin -causes Lactic acidosis  Ibuprofen & Aspirin - increase your risk of developing gastrointestinal ulcers and bleeding - may cause severe abdominal pain, bloating, loss of appetite, and/or black, tarry stools  Albuterol & Magnesium Hydroxide (MAALOX) - irregular heart rhythm that may be serious and potentially life-threatening: risk is increased if you have low blood levels of magnesium or potassium

ASSESMENT  PHYSIOLOGY STOMACH

Breaks down large food particles into smaller pieces so that they can be processed more easily. It is intraperitonal and located in the left epigastric regions of the abdomen. 

Hydrochloric acid -secreted from the parietal cells in the body of the stomach.

 PATHOPHYSIOLOGY

Peptic ulcer - is a circumscribed loss of the mucus membrane of the GIT system exposed to gastric juices containing acid & pepsin.  Peptic ulcer occur most common in: -esophagus -stomach*

Imbalance Of This Factors Causes Peptic Ulcer Disease:  Aggressive factors -bile, acid and pepsin  Defensive factors -mucus, bicarbonates and PG

Other contributory factors: 

Helicobacter pylori  NSAIDs  Stress  Ethanol  Tobacco

Complications of PUD 1. Bleeding - occurs in 25-30% of patients -most frequent complication and maybe life threatening - for 25% of ulcers deaths 2. Perforation -occurs in about 5% of the patients -s for 2/3 of ulcer deaths 3. Obstruction from edema or scarring

PHARMACOTHERAPHY  Misoprostol -may be used to prevent gastric ulcers caused by non-steroidal anti- inflammatory drugs.

 Consider that the interaction may be unavoidable if ibuprofen is istered more than once daily.  Avoid ibuprofen if possible or give it 2 hours after aspirin.  Consider alternative: Acetaminophen* reduces pain and lowers fevers. Unlike aspirin and other NSAIDS, acetaminophen is believed to be safe for people with ulcers.

NON-PHARMACOTHERAPY  Refer the patient to a smoking-cessation program  Stress Reduction  Avoidance of dietary irritants (Alcohol)  Physical activity can help reduce some kinds of discomfort, such as arthritis pain.

REFERENCES -MEDSCAPE -WEBMD -DRUGS.COM -MEDLINEPLUS MEDICAL ENCYLOPEDIA -Katzung et.al., Basic and Clinical Pharmacology (p. 355 &757)