Acid Peptic Disease Case Study

1. Acid Peptic Disease Case Study Charmaine D. Rochester, PharmD, CDE, CDM, BCPS Asst Professor, University of MD School of Pharmacy

2. 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.

3. “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

4. 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.

5. 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.

6. 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

7. 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

8. 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.

9. 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)

10. 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 non-icteric. PERRLA. Fundi normal

11. 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.

12. 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) MCH: 23 (27-31)

13. 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.

14. Risk Factors Pathophysiologic Explanation Risk Factors Present in this Patient

15. Risk Factors Pathophysiologic Explanation Other Risk Factors to Investigate

16. Sign Pathophysiologic Explanation Sign or Symptoms of Peptic Ulcer Disease Present

17. Sign of Complication Pathophysiologic Explanation Sign or Symptoms of Complications Present

18. Additional Data Needed: Define/Assess Acid Peptic Disease/Complications

19. 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.

20. 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

21. 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.

22. 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

23. Risk Factors Pathophysiologic Explanation Risk Factors Present in this Patient

24. Sign Pathophysiologic Explanation Sign or Symptoms of Reflux

25. Sign of Complication Sign or Symptoms of Complications Present

26. Recommendations/Counseling