Pharmacotherapy Case Study 2: Peptic Ulcer Disease By: Dr. Nehad Ahmed

 

Pharmacotherapy Case Study 2: Peptic Ulcer Disease By: Dr. Nehad Ahmed

 

Chief Complaint:

A 45-year-old male presents with complaints of upper abdominal pain, nausea, and occasional bloating for the past 2 weeks. The pain is described as burning, located in the epigastric region, and occurs mostly after meals, especially when he is hungry.

Subjective Data:

History of Present Illness (HPI):

·        The patient reports a dull, burning pain in the upper abdomen that has persisted for 2 weeks. The pain occurs 1-2 hours after eating and is partially relieved by eating or taking antacids.

·        The pain is most severe when the patient is hungry or after consuming spicy or acidic foods.

·        Associated symptoms include nausea, occasional bloating, and early satiety.

·        Denies vomiting, melena, or hematemesis.

·        The patient also notes increased frequency of heartburn and burping.

Past Medical History (PMH):

·        No significant past medical history.

·        Denies any history of gastrointestinal diseases (e.g., GERD, gastritis).

·        Denies any previous diagnoses of ulcers or gastrointestinal bleeding.

·        No history of diabetes, cardiovascular disease, or chronic kidney disease.

Medications:

·        Over-the-counter (OTC) antacids (calcium carbonate) as needed, about 2-3 times a week.

·        No regular medications.

Allergies:

·        No known drug allergies (NKDA).

Social History:

·        Works as an office manager.

·        Denies smoking.

·        Occasional alcohol use (1-2 drinks per week).

·        No illicit drug use.

·        Reports high levels of work-related stress.

Family History:

·        Father with a history of hypertension and heart disease.

·        Mother with a history of peptic ulcers diagnosed at age 50.

Review of Systems (ROS):

·        Gastrointestinal: Positive for epigastric burning pain, nausea, occasional bloating, and early satiety. Denies vomiting, hematemesis, melena, or diarrhea.

·        Cardiovascular: Denies chest pain, palpitations, or shortness of breath.

·        Respiratory: Denies cough, shortness of breath, or wheezing.

·        Neurological: No headaches, dizziness, or syncope.

·        Musculoskeletal: No joint pain or muscle weakness.

Objective Data:

Vital Signs:

·        Blood Pressure: 126/78 mmHg

·        Heart Rate: 76 bpm

·        Respiratory Rate: 16 breaths/min

·        Temperature: 98.6°F (37°C)

·        Weight: 180 lbs (81.6 kg)

·        Height: 5'10" (178 cm)

 

Physical Exam:

·        General: Alert, oriented, and in no acute distress.

·        Abdomen: Soft, non-tender to light palpation, with mild tenderness on deep palpation in the epigastric region. No signs of peritoneal irritation (no rebound tenderness). Bowel sounds are normal. No palpable masses.

·        Other Systems: Within normal limits (cardiovascular, respiratory, neurological, musculoskeletal).

Labs and Imaging:

·        Complete Blood Count (CBC): Normal WBC, hemoglobin, and platelet count.

·        Basic Metabolic Panel (BMP): Normal electrolytes and renal function.

·        Liver Function Tests (LFTs): Normal.

·        Helicobacter pylori testing: Urea breath test positive.

·        Endoscopy: Findings consistent with a duodenal ulcer (shallow, round ulcer with a clean base).

·        Stool Occult Blood Test: Negative.

Assessment:

The patient is diagnosed with Peptic Ulcer Disease (PUD), likely caused by Helicobacter pylori infection, as indicated by the positive urea breath test and endoscopic findings.

The most likely type of ulcer is duodenal ulcer, given the nature of the pain (relieved by food intake), and the patient’s risk factors, including stress and a family history of peptic ulcers.

Plan:

Pharmacologic Treatment:

1.     Proton Pump Inhibitor (PPI):

o   Omeprazole 20 mg orally once daily for 4-6 weeks to reduce gastric acid secretion and promote ulcer healing.

2.     Antibiotics (for H. pylori eradication):

o   Clarithromycin 500 mg orally twice daily for 14 days.

o   Amoxicillin 1000 mg orally twice daily for 14 days.

o   Alternatively, if the patient is allergic to penicillin, use Metronidazole 500 mg orally twice daily instead of amoxicillin.

3.     Antacid (as needed for symptom relief):

o   Calcium carbonate 500 mg after meals and at bedtime for occasional heartburn.

Non-pharmacologic Treatment:

·        Dietary modifications: Recommend avoiding spicy, acidic foods, caffeine, and alcohol, which may irritate the ulcer.

·        Stress management: Suggest relaxation techniques such as deep breathing, exercise, or counseling for stress management.

·        Smoking cessation: Encourage smoking cessation if applicable (although the patient denies smoking).

·        Follow-up: After 4-6 weeks, repeat endoscopy to assess ulcer healing and confirm H. pylori eradication.

Patient Education:

·        Explain the importance of completing the full course of antibiotics to eradicate H. pylori.

·        Instruct the patient to avoid nonsteroidal anti-inflammatory drugs (NSAIDs) to prevent further ulcer irritation.

·        Advise the patient to take PPIs before meals and to follow the prescribed medication schedule.

Follow-Up:

·        Schedule follow-up in 4-6 weeks to assess symptom resolution and review the results of a follow-up urea breath test (if needed) to confirm eradication of H. pylori.