Transcript Acid Peptic Disease Case Study

Acid Peptic Disease Case Study
Charmaine D. Rochester, PharmD, CDE,
CDM, BCPS
Asst Professor, University of MD School
of Pharmacy
Objectives
At the completion of this exercise and given
a case, the student will be able to:
• Identify pertinent subjective and objective
data necessary for definition of acid peptic
disease and related complications.
• Explain the pathophysiologic basis for
specific historical risk factors, signs, or
symptoms of acid peptic disease.
• Given a case, explain proposed
pathophysiologic causes of physical and
laboratory findings.
“Coffee Colored Sputum”
Primary Care Clinic 10/19/06 1 PM
• CC: I have been having stomach
pains for the past 2 weeks, but it
is getting increasingly worse
HPI: TP is a 69 yo female who
comes to clinic. The patient
describes the stomach pain as a
burning, gnawing-like sensation
felt in the mid-epigastric region.
The pain does not radiate to the
back and is associated with
occasional nausea. She believes
this is due to the stress of losing
her husband 2 months ago.
HPI Cont’d
The pain is relieved by food or milk
although it is made worse
sometimes by a large meal. She
describes dark brown "coffee
ground" vomit one hour after her
dinner yesterday. She denies
constipation but has had diarrhea
recently, with very dark stools over
the last day or two.
PMH: Osteoarthritis x 9 yrs, HTN,
Dyslipidemia
FH: Non contributory; husband died
2 months ago
SH: Cigarette smoking 1ppd x 40
yrs; no alcohol; no caffeine
beverages
Medication History
Meds: Aspirin 325 mg 2 tabs q 4-6
hours for joint pains x 1 year,
Tramadol 100 mg bid as needed q
4-6 hr (at least 10 daily), HCTZ 25
mg q day x 30 yrs, Pravastatin 40
mg daily x 10 yrs; Mylanta as
needed for stomach pains
Allergies: NKDA
Review of Systems
HEENT:Occasional headache
relieved by aspirin or
acetaminophen. Denies blurred
vision, tinnitus, epistaxis.
RESP: Has some dyspnea on
moderate exertion. Denies
pneumonia, sputum production,
hemoptysis.
Review of Systems Cont’d
COR: Denies chest pain, ankle
edema, orthopnea, PND. Has HTN
GI: As per HPI
GU: Denies dysuria, hematuria,
urgency, frequency, flank pain.
EXT: arthritis (pain, no swelling or
redness of joints)
Physical Examination
Gen: Looks slightly older than stated age.
Appears weak but in no acute distress.
Pulse: 108 sitting, reg; 128 standing, reg
BP: 144/62 mmHg sitting 123/42 mmHg
standing R: 18; Temp 98.6 F
Wt: 142 lbs ( from 150 lbs in 2 weeks)
HEENT: Pale conjunctiva, sclera nonicteric. PERRLA. Fundi normal
Physical Examination
Chest: Hyperresonance to percussion.
 expiratory phase.  A/P diameter.
Scattered expiratory wheezes. No
crackles or rhonchi.
Cor: S1S2 WNL. - gallops/murmurs/rubs
Abd: Slight epigastric tenderness, no
rebound, hepatomegaly or
splenomegaly
Ext: No deformities, limited ROM in
fingers and wrists. No nodules,
swelling, or redness. No edema.
Labs
Electrolytes: WNL
Glucose: 106 (60-120)
HCT: 31 (36-47)
BUN: 36
(10-20)
Creat: 1.2 (0.8-1.5)
Hgb: 11
(12-16)
MCV: 72 (82-92)
(27-31)
MCH:
23
Labs Cont’d
Urinalysis: WNL
Stool: Hemoccult +ve
CXR: flattened diaphragm
X-rays of hand and knees reveal
osteoporosis, diffuse joint space
narrowing and cartilaginous
destruction. No bone spurs seen.
Risk Factors Present in this
Patient
• Risk Factors
• Pathophysiologic
Explanation
Other Risk Factors to Investigate
• Risk Factors
• Pathophysiologic
Explanation
Sign or Symptoms of Peptic
Ulcer Disease Present
• Sign
• Pathophysiologic
Explanation
Sign or Symptoms of
Complications Present
• Sign of Complication
• Pathophysiologic
Explanation
Additional Data Needed:
Define/Assess Acid Peptic
Disease/Complications
Ritehelp Pharmacy
• CC: Worsening heartburn x 2 months
• HPI: TY is a 30 yr old 100 kg, 60” tall
female who is at the pharmacy counter.
She states she has significant pain
every day. The pain occurs while she is
lying on the sofa watching TV after a
heavy meal at nights. She said that she
has always had heartburn, but it was
never as terrible as now.
HPI
• She describes chest pain, foul
taste fluid in her mouth and bad
breath. She states that the pain is
9 out of 10 on a pain scale. She
describes recent hoarseness x 1
month, but denies coughing, cold,
flu or any upper respiratory
symptoms
HPI Cont’d
• Her evening meal usually consist of a
high fat chocolate shake or ice cream
for dessert and 2 – 3 beers. She
frequently eats lasagne from Olive
Garden and drinks orange or grapefruit
juice or iced tea with lemons
• She generally smokes about ½ pack
cigarettes before bedtime with 2 cups
coffee and suck peppermints
postprandial in order to sleep.
PMH and Medications
• PMH: Insomnia x 4 years, Reflux x 4
years; HTN x 2 years
• Meds: Estrogen/progesterone – 1 pill daily
for contraception; Nicotine transdermal
patch 21 mg daily for smoking cessation;
amitriptyline 25 mg at bedtime for sleep;
HCTZ 25 mg daily
• Allergies: NKDA
Risk Factors Present in this
Patient
• Risk Factors
• Pathophysiologic
Explanation
Sign or Symptoms of Reflux
• Sign
• Pathophysiologic
Explanation
Sign or Symptoms of
Complications Present
• Sign of Complication
Recommendations/Counseling