CASE ANALYSIS 3 ON APD/GERD

DEMOGRAPHIC DETAILS:

AGE:17yrs GENDER: Male

UNIT/ HOSPITAL: GM/RVM IPNO: 170804026

DOA: - 18-08-17 DOD:-21-08-18

REASON FOR ADMISSION: Pain in abdomen(epigastric region ,pricking type) ,low grade fever
associated with chills,rigors,cold since 5 days

PAST MEDICAL HISTORY:

N/k/c/o DM/HTN/PTB

FAMILY HISTORY: NS

SOCIAL HISTORY: NS

ALLERGIES: NKA

PROVISIONAL DIAGNOSIS: PAIN ABDOMEN ! EVALUATION(APD)

FINAL DIAGNOSIS: GERD

LABORATORY DATA:
Haematology:
Lab Parameter DAY-1 Normal value
HB 13.7gms% 13-18gms%
WBC 8900c/cmm 4000-11000c/cmm
RBC 4.8m/cmm 4.3-5.7c/mm
DLC=N+L+E+M+B 77+18+03+02+00
PLATELET COUNT 1.92lakhs 1.5-4lakhs

Biochemistry:
Lab Parameter DAY-1 Normal value
RBS 95mg/dl 60-110mg/dl
Sr. Creatinine 1.1mg/dl 0.5-1.5mg/dl
Bloodurea 30mg/dl 10-50mg/dl
Sodium 137mmol/l 135-150mmol/l
Potassium 3.50mmol/l 3.5-5.0mmol/l
Chloride 98mmol/l 95-105mmol/l
i.calcium 1.17mmol/l
Sr.Amylase 37

DAY-WISE ASSESSMENT:
DAY 1: DAY 2: DAY 3:
O/E: pt c/c , O/E: pt c/c , O/E: pt c/c ,
Temp:99F Temp:98F Temp:98F
BP: 100/70mmHg BP: 140/70mmHg BP: 110/70mmHg
PR:74 bpm PR: 78 bpm PR: 78 bpm
c/o fever, abdomen pain (epigastric c/o black colored stools ,loss No fever, no abdomen pain,
region) pricking type 10-15min of appetite improved appetite.
duration 2-3 episodes a day
h/o nausea no relation with food c/o chills
ADV: Avoid spicy food
DAY 4:
O/E: pt c/c ,
Temp:N
BP: 120/80mmHg
PR: 98 bpm
No fresh complaints
ADV: DISCHARGE

TREATMENT:
Name of medication Dose Route of Frequency Day of Day of
administration admission stopping
I.IVF.RL 100ml I.V hourly D1 D4

I.CEFTRIAXONE 1000mg I.V STAT/BD D1 D4

I.PANTOPRAZOLE 40mg I.V BD D1 D3
I.ONDANSETRON 4mg I.V BD D1 D3
T.ACETAMINOPHE 650mg P.O TID D1 D4
N
SYP.SUCRALFATE 10ml P.O TID D1 D4
I.HYOCINE BUTYL 10mg I.M BD D1 D4
BROMIDE
T.TRAMADOL+ACE 37.5mg+350mg P.O BD D1 D4
TAMINOPHEN
T.RABEPRAZOLE 20mg P.O OD D4 D4

DISCHARGE MEDICATION:
Name of medication Dose Route of Frequency Duration
administration of usage
T.RABEPRAZOLE 20mg P.O OD X 14days
SYP.SUCRALFATE 10ml P.O TID X 10days
T.TRAMADOL+ACETAMINO 37.5mg+350mg P.O BD SOS
PHEN
T.CEFPODOXIME 200mg P.O BD X10days
T.RABIPRAZOLE 20mg P.O OD X6 days
T.ALBENDAZOLE 400mg P.O OD STAT X 6
days

PATHOPHYSIOLOGY:
.

PHARMACEUTICAL CARE PLAN:

SUBJECTIVE EVIDENCES: Pain in abdomen(epigastric region ,pricking type) ,low grade fever
associated with chills,rigors,cold since 5 days

OBJECTIVE EVIDENCES: CBP ,Bio-chemistry reports

GOALS OF TREATMENT:
• Limit your symptoms such as pain in abdomen , cold, fever.
• Increase your overall health with regular activity.
• Improve the present condition with medicines

TREATMENT OPTIONS:
Non-Pharmacological:
ALCOHOL
Frequent consumption of alcohol is a risk factor for reflux symptoms . The habits of drinking wine
or beer increase the risk of reflux . Alcohol consumption is a risk factor.Avoid alcohol consumption
COFFEE
Coffee consumption is associated with GERD
DIET
The consumption of sweets and white bread is associated with symptoms of reflux
Fruit consumption has a protective effect on reflux symptoms.
Protein intake is associated with erosive GERD, and fiber, with a lower risk of GERD.
Excessive consumption of food and sweet food is associated with GERD.
High-fat diet does not increase the number of reflux episodes, or acid esophageal exposure15
POSTURE
Working in an inclined position is a risk factor for nonerosive GERD.
GERD episodes are triggered by postures. INCLINED HEAD OF THE BED Sleeping with a wedge-shaped
support is associated with less acid exposure than in the horizontal position
Raising the head of the bed (28 cm) reduces the number of reflux episodes and pH time < 517
NIGHT MEALS
 The later the night the meal is, the higher the rate of reflux episodes, especially in obese individuals and in
those with erosive GERD.
Going to bed immediately after dinner is associated with increased risk of GERD, especially within a time
period of less than 3 hours.
PHYSICAL EXERCISE
Physical activity seems to have a protective effect against GERD.
STRESS AND FATIGUE
GERD episodes are triggered by stress and fatigue. Stress is among the risk factors for GERD
1. Pharmacological:
General treatment options :
Antacids:
Antacids were the standard treatment and are still effective in controlling mild symptoms of GERD.
Antacids should be taken after each meal and at bedtime.
H2 receptor antagonists and H2 blocker therapy
H2 receptor antagonists are the first-line agents for patients with mild to moderate symptoms and grades
I-II esophagitis.
ranitidine (Zantac), cimetidine (Tagamet), famotidine (Pepcid), and nizatidine (Axid).

Additional H2 blocker therapy has been reported to be useful in patients with severe disease (particularly
those with Barrett esophagus) who have nocturnal acid breakthrough.
Proton pump inhibitors:
PPIs are the most powerful medications available for treating GERD. These agents should be used only
when this condition has been objectively documented. They have few adverse effects and are well
tolerated for long-term use

Available PPIs include omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex), and
esomeprazole
Individual PPIs (omeprazole, lansoprazole, pantoprazole, and rabeprazole) for relief of symptoms at 8
weeks. For symptom relief at 4 weeks, esomeprazole 20 mg was equivalent, but esomeprazole 40 mg
superior, to omeprazole 20 mg)
Patient specific treatment options: (drug with dose &frequency)
I.IVF.RL 100ml I.V hourly

I.CEFTRIAXONE 1000mg I.V STAT/BD

I.PANTOPRAZOLE 40mg I.V BD
I.ONDANSETRON 4mg I.V BD
T.ACETAMINOPHEN 650mg P.O TID
SYP.SUCRALFATE 10ml P.O TID
I.HYOCINE BUTYL 10mg I.M BD
BROMIDE
T.TRAMADOL+ACETAMIN 37.5mg+350mg P.O BD
OPHEN
T.RABEPRAZOLE 20mg P.O OD

GOALS ACHIEVED:
Improved appetite
Fever and chills subsided
Decreased abdominal pain

PROBLEMS IDENTIFIED/MANAGEMENT:
  Drug-drug interactions
SIGNIFICANT MONITOR CLOSELY:

PATIENT COUNSELLING:

About disease:

Gastroesophageal refers to the stomach and esophagus. Reflux means to flow back or return. Therefore,
gastroesophageal reflux is the return of the stomach's contents back up into the esophagus.

In normal digestion, the lower esophageal sphincter (LES) opens to allow food to pass into the stomach and
closes to prevent food and acidic stomach juices from flowing back into the esophagus. Gastroesophageal
reflux occurs when the LES is weak or relaxes inappropriately, allowing the stomach's contents to flow up
into the esophagus.

SYMPTOMS:
Heartburn, also called acid indigestion, is the most common symptom of GERD and usually feels like a
burning chest pain beginning behind the breastbone and moving upward to the neck and throat. Many people
say it feels like food is coming back into the mouth leaving an acid or bitter taste.

About medication:

1.T.Rabeprazole:

For gastric problems

About lifestyle modifications:
Lifestyle modifications include the following:
 Losing weight (if overweight)
 Avoiding alcohol, chocolate, citrus juice, and tomato-based products (2005 guidelines from the American College of
Gastroenterology [ACG] also suggest avoiding peppermint, coffee, and possibly the onion family [7] )
 Avoiding large meals
 Waiting 3 hours after a meal before lying down
 Elevating the head of the bed by 8 inches

DIET:
 The consumption of sweets and white bread is associated with symptoms of reflux
 Fruit consumption has a protective effect on reflux symptoms.
 Protein intake is associated with erosive GERD, and fiber, with a lower risk of GERD.
 Excessive consumption of food and sweet food is associated with GERD.
 High-fat diet does not increase the number of reflux episodes, or acid esophageal exposure15