CASE STUDY ON

ACID PEPTIC
DISEASE AND
UPPER
RESPIRATORY
INFECTION
A 39 year old female patient was admitted in the hospital on 20.08.2019.
CHIEF COMPLAINTS (C/O):
C/O
 cold,
 cough * 1 week
 large amount of sputum expectoration,
 indigestion
 nausea+
HISTORY OF PRESENT ILLNESS (H/O):
• No H/O burning micturition
• H/O regular menstruation
PAST MEDICAL HISTORY:
Nil H/O relevant
PAST MEDICATION HISTORY:
Nil
PERSONAL HISTORY/ SOCIAL HABITS:
Patient takes mixed diet
Husband – type 2 DM and HTN
PHYSICAL OR SYSTEMIC EXAMINATION:
• Patient was conscious and oriented
• Hydration is fair
• TEMP: afebrile
• PULSE: 84beats/min
• BP: 110/80 mm Hg.
• CVS: S1 and S2 sounds (+)
• RS: NVBS (+)
• CNS: NFND (+)
• P/A: soft
LAB INVESTIGATIONS:
PARAMETERS OBSERVED VALUE NORMAL VALUE

COMPLETE BLOOD COUNT:

o Hb 10.4 mg/dl 14-18 mg/dl
o ESR 9/22 mm/hr 0-22 mm/hr
o DC: N% 68% 40% - 80%
o L% 28% 20% - 40%
o E% 4% 1% - 6%
o TOTAL WBC 7900cells/cu.mm 4500 – 11000 cells/ cu.mm
BLOOD SUGAR:
RBS 103 mg/dl 79 – 160 mg/dl
RENAL FUNCTION TESTS:
BUN 27 mg/dl 7 – 20 mg/dl
Creatinine 0.6 mg/dl 0.6 – 1.1 mg/dl
OTHER TESTS:
NIL
IMPRESSION:
--
DIAGNOSIS:

ACID PEPTIC DISEASE / UPPER RESPIRATORY INFECTION

DRUG CHART:
s.no GENERIC NAME DOSE R.O.A FREQUENC DURATION
DRUGS Y
BRAND NAME
1. T.CEFIXIME CEPHALOSPOR 1g P/O BD D1 TO D2
IN
2. T.MONTEX IC MONTELUKAS 10mg P/O HS D1 TO D2
T+LEVOCETRI
ZINE
3. T. PARA ACTAMINOPHE 500mg P/O BD D1 TO D2
N
4. T.BCT B COMPLEX 1tb P/O OD D1 TO D2

5. COUGH CODIENE 1 tsp P/O HS D1 TO D2

SYRUP
s.n GENERIC DOSE R.O.A FREQUENC DURATION
o DRUGS NAME Y
BRAND NAME

6. T. ILAPRO ILAPRAZOLE 40mg P/O OD D1 TO D2

7. T. ARCALION SULBUTAMINE 200mg P/O OD D1 TO D2

DRUG INTERACTIONS:
No drug interactions.
SOAP NOTES

SUBJECTIVE A 39 year old female was admitted in the hospital for the complaints of
 cold,
 cough * 1 week
 large amount of sputum evacuation,
 indigestion
 nausea+
The patient has no history DM and HTN and the patient has regular menstruation.

OBJECTIVE The patient was conscious and oriented. Her Hb level was low and the other tests were normal.

ASSESSMENT Diagnosed as acid peptic disease and upper respiratory infection.

PLAN T.Cefixime,T.montex IC, T.para, T.BCT, cough surup, T.ilapro, T. arcalion are the medicines
patient taken.