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    Case Study On Peptic Ulcer

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    FHAMITHA
    1. A 40-year old male presented with a chief complaint of abdominal pain for 15 days and vomiting for 2 days. Physical examination and lab tests revealed mild to moderate dehydration. 2. Endoscopy revealed ulcers in the stomach. The patient was diagnosed with acid peptic disease. 3. Treatment included IV fluids, omeprazole, ranitidine, antacids, probiotics, and metronidazole. The patient was counseled on lifestyle modifications and adherence to the medication regimen.

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    Case Study On Peptic Ulcer

    Uploaded by

    FHAMITHA
    492 views11 pages
    1. A 40-year old male presented with a chief complaint of abdominal pain for 15 days and vomiting for 2 days. Physical examination and lab tests revealed mild to moderate dehydration. 2. Endoscopy revealed ulcers in the stomach. The patient was diagnosed with acid peptic disease. 3. Treatment included IV fluids, omeprazole, ranitidine, antacids, probiotics, and metronidazole. The patient was counseled on lifestyle modifications and adherence to the medication regimen.

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    Case Study on Peptic Ulcer

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    1. A 40-year old male presented with a chief complaint of abdominal pain for 15 days and vomiting for 2 days. Physical examination and lab tests revealed mild to moderate dehydration. 2. Endoscopy revealed ulcers in the stomach. The patient was diagnosed with acid peptic disease. 3. Treatment included IV fluids, omeprazole, ranitidine, antacids, probiotics, and metronidazole. The patient was counseled on lifestyle modifications and adherence to the medication regimen.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    492 views11 pages

    Case Study On Peptic Ulcer

    Uploaded by

    FHAMITHA
    1. A 40-year old male presented with a chief complaint of abdominal pain for 15 days and vomiting for 2 days. Physical examination and lab tests revealed mild to moderate dehydration. 2. Endoscopy revealed ulcers in the stomach. The patient was diagnosed with acid peptic disease. 3. Treatment included IV fluids, omeprazole, ranitidine, antacids, probiotics, and metronidazole. The patient was counseled on lifestyle modifications and adherence to the medication regimen.

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    © All Rights Reserved
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    of 11

    CASE STUDY ON

    ACID PEPTIC
    DISEASE
    A 40 year old male was admitted in the hospital on 17.8.2018.

    CHIEF COMPLAINTS:
    C/O Abdominal pain on & off 15 days
    Vomiting for 2 days * 3 episodes

    HISTORY OF PRESENT ILLNESS:


    H/O Moderate dehydration
    Epigastric pain
    PAST MEDICAL HISTORY:
    N/K/C/O DM/SHT/TB

    PAST MEDICATION HISTORY:


    Nil

    PERSONAL HISTORY AND HABITS:


    Mixed diet and non alcoholic
    GENERAL EXAMINATION:
    TEMP: Afebrile
    PULSE: 86beats/min
    BP: 130/70mmhg

    SYSTEMIC EXAMINATION:
    CVS: S1 S2 (✚) no murmur
    RS: soft, tender (✚)
    ABD: BAE(✚)
    LAB INVESTIGATIONS:

    PARAMETERS OBSERVED VALUE NORMAL VALUE


    HB 12.9g/dl 12-16g/dl
    ESR 12mm/hr <15mm/hr
    DC : P 65% 50-81%
    L 31% 14-44%
    E 4% 1-5%
    TOTAL WBC 9400 cells/cumm 4000-11000 cells/cumm
    PCV 38% 30-43%
    Platelet count 3.21 lakhs/cumm 1-4lakhs/cumm
    OTHER TESTS:
     Endoscopy
     USG ABDOMEN

    IMPRESSION:
     USG ABDOMEN- Normal study
     In Endoscopy –ulcers were found.

    DIAGNOSIS:
    Acid peptic disease
    DRUG CHART:
    S. BRAND NAME GENERIC NAME DOSE ROA FREQ DURATION
    NO

    1. I.V FLUIDS Normal saline/Ringer’s 275ml IV OD Day 1- day 7


    lactate 275ml
    2. CAP.OMEZ omeprazole 20mg P/O BD Day 1- day 7

    3. T.RANTAC Ranitidine 150mg P/O BD Day 1- day 7

    4. T.BCT B.complex 1cap P/O OD Day 1- day 7

    5. T.DICYCLOMINE Dicyclomine. Hcl 10mg P/O BD Day 1- day 7

    6. CAP.BIFILAC lactobacillus 1 cap P/O OD Day 1- day 7

    7. T.FLAGYL metronidazole 400mg P/O BD Day 1- day 7


    DRUG INTERACTIONS:
    no drug interactions
    SOAP NOTES:

    SUBJECTIVE A 45 year old male patient was admitted with the c/o abdominal pain * night along with
    vomiting in 3 episodes.

    OBJECTIVE Upon admission physical and systemic examination lab investigations should mild to
    moderatel evels of dehydration.

    ASSESSMENT Based on the subjective and objective findings, the patient was assessed to have acid
    peptic disease. Acid peptic disorders are the resultof distinctive, but overlapping
    pathogens mechanisms leading to either excessive acid secretion or diminished
    mucosal defense.

    PLAN The plan implemented for this patients was adequate and patient was advised to adhere
    to drug therapy as long as prescribed.
    PATIENT COUNSELING:
     REGARDING DISEASE:

     Peptic ulcer disease (PUD), also known as a peptic ulcer or stomach ulcer, is a break in the lining of the
    stomach, first part of the small intestine, or occasionally the lower esophagus.

     An ulcer in the stomach is known as a gastric ulcer while that in the first part of the intestines is known as
    a duodenal ulcer.

     The most common symptoms are waking at night with upper abdominal pain or upper abdominal pain that
    improves with eating. The pain is often described as a burning or dull ache.

     Other symptoms include belching, vomiting, weight loss, or poor appetite. About a third of older people
    have no symptoms.

     Complications may include bleeding, perforation, and blockage of the stomach. Bleeding occurs in as
    many as 15% of people.
    • ABOUT MEDICATIONS:
     Omeprazole reduces the gastric acid should be taken once daily.
     Ranitidine reduces the amount of acid produced in the stomach.
     Do not miss the dose or double the dose.
    REGARDING LIFESTYLE:
     Encourage the patient to take plenty of fluids. The aim is to prevent dehydration.
    The fluid lost in their vomit and/or diarrhoea needs to be replaced. Patient should
    continue with their normal diet and usual drinks.
     Avoid fruit juices or fizzy drinks, as these can make diarrhoea worse.
     Don't let share towels and flannels.
     Don't let them help to prepare food for others.
     Avoid fried and oily food items, fast food etc.
     Food should be taken at right time.
     Consume plenty of curd and tender coconut.

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