111

■■ HPI

CHAPTER 35
Justine Ward is a 67-year-old woman who presents to her pri-
mary care physician with complaints of episodic epigastric pain
for the past 6 weeks. Her pain is nonradiating. It is sometimes
worse with meals, but sometimes eating helps improve the pain.
She has been experiencing occasional nausea, bloating, and
heartburn. She denies any change in color or frequency of bowel
movements. She does not have a history of PUD or GI bleeding.
She mentions that she has been having frequent headaches for
the past month and has been taking naproxen sodium one to two

Peptic Ulcer Disease

times daily.

■■ PMH
CAD with drug-eluting stent placement × 3 months
Hypothyroidism × 22 years
Hyperlipidemia × 10 years
Lactose intolerance × 47 years
Postmenopausal; LMP ~13 years ago

■■ FH
Her mother died at the age of 75 from lymphoma. Her father is
alive and has a history of glaucoma, prostate cancer, and AMI at age
70. She has five siblings who are alive. All siblings have a history of
hypertension and hyperlipidemia.

■■ SH
She is married and has raised three children; she is not employed
outside the home. She has never smoked and drinks one to two

35
glasses of wine most days of the week.

■■ Meds
Plavix 75 mg PO daily
PEPTIC ULCER DISEASE Lisinopril 5 mg PO daily
Metoprolol tartrate 25 mg PO twice daily
Feel the Burn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Level II Aspirin 325 mg PO daily
Ashley H. Meredith, PharmD, FCCP, BCACP, BCPS, CDE Synthroid 125 mcg PO daily
Atorvastatin 80 mg PO daily
MVI tablet PO daily
Tums 500 mg PO PRN stomach pain
LEARNING OBJECTIVES Naproxen sodium 220 mg PO PRN headache (one to two times daily
for the past month)
After completing this case study, the reader should be able to: Lactaid one tablet PO PRN dairy product consumption
•• List the options for the evaluation and treatment of a patient with
symptoms suggestive of peptic ulcer disease (PUD). ■■ All
•• Identify the desired therapeutic outcomes for patients with PUD. NKDA
•• Identify the factors that guide selection of a Helicobacter pylori
eradication regimen and improve adherence with the regimen. ■■ ROS
Unremarkable except for complaints noted above
•• Compare the efficacy of three- and four-drug H. pylori treatment
regimens and regimens lasting 7, 10, and 14 days or provided in
sequential order. ■■ Physical Examination
•• Create a treatment and monitoring plan for a patient diagnosed Gen
with PUD, given patient-specific information. Slightly overweight woman in moderate distress

VS
PATIENT PRESENTATION BP 110/72 left arm (seated), P 99, RR 16 reg, T 37.2°C; Wt 149.6 lb
(68 kg), Ht 5′3″ (160 cm)
■■ Chief Complaint
“My stomach has been hurting really badly for the past month or so. Skin
It seems to get worse at night.” Warm and dry

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 112
HEENT ■■ Assessment
Normocephalic; PERRLA; EOMI PUD with duodenal ulcer and anemia
SECTION 4

Chest
CTA QUESTIONS
CV Collect Information
RRR; S1 and S2 normal; no MRG 1.a. What subjective and objective information indicates the pres-
ence of PUD?
Gastrointestinal Disorders

Abd 1.b. What additional information is needed to fully assess this

Soft; mild epigastric tenderness; (+) BS; no splenomegaly or masses; patient’s PUD?
liver size normal

Rect Assess the Information

Nontender; stool heme (+) 2.a. Assess the severity of PUD based on the subjective and objec-
tive information available.
Ext 2.b. Create a list of the patient’s drug therapy problems and priori-
Normal ROM; no cyanosis, clubbing, or edema tize them. Include assessment of medication appropriateness,
effectiveness, safety, and patient adherence.
Neuro
CN II–XII intact; A&O × 3 Develop a Care Plan
3.a. What are the goals of pharmacotherapy for this case?
■■ Labs
3.b. What nondrug recommendations might be useful for this
Na 142 mEq/L Hgb 10.1 g/dL Ca 9.5 mg/dL
patient?
K 4.7 mEq/L Hct 30% Mg 2.2 mEq/L
Cl 98 mEq/L Plt 320 × 103/mm3 Phos 3.8 mg/dL 3.c. In the absence of information about the presence of H. pylori,
CO2 30 mEq/L WBC 7.6 × 103/mm3 Albumin 5.0 g/dL what pharmacologic alternatives are available to treat PUD?
BUN 8 mg/dL MCV 72 μm3 TSH 2.4 μU/mL
3.d. Create an individualized, patient-centered, team-based care
SCr 0.7 mg/dL Retic 0.4% TC 142 mg/dL
FBG 92 mg/dL Fe 48 mcg/dL LDL 64 mg/dL plan to optimize medication therapy for this patient’s PUD and
HDL 53 mg/dL other drug therapy problems. Include specific drugs, doses,
TG 127 mg/dL dosage forms, schedules, and durations of therapy.

■■ EGD
Justine’s PCP referred her for a nonemergent EGD, which revealed
Implement the Care Plan
a 5.5-mm superficial ulcer in the superior duodenum. The ulcer 4.a. What information should be provided to the patient to enhance
base was clear and without evidence of active bleeding (Fig. 35-1). compliance, ensure successful therapy, and minimize adverse
In addition, inflammation of the duodenum was detected and effects?
biopsied. 4.b. Describe how care should be coordinated with other healthcare
providers.

Follow-up: Monitor and Evaluate

5.a. What clinical and laboratory parameters should be used to
evaluate the therapy for achievement of the desired therapeutic
outcome and to detect or prevent adverse effects?
5.b. Develop a plan for follow-up that includes appropriate time
frames to assess progress toward achievement of the goals of
therapy.

■■ CLINICAL COURSE
At the time of the EGD, a biopsy of the duodenal mucosa was
taken and indicated the presence of inflammation and abundant
H. pylori–like organisms.

■■ FOLLOW-UP QUESTIONS
1. What is the significance of finding H. pylori in the duodenal
FIGURE 35-1. Endoscopy depicting duodenal ulcer with flat pigmented
biopsy?
spots as noted by arrows. (Reprinted with permission from Jameson JL,
Fauci AS, Kasper DL, et al, eds. Harrison’s Principles of Internal Medicine. 20th ed. 2. Based on this new information, how would you modify your
New York, NYL McGraw-Hill Education, 2018.) goals for treating this patient’s PUD?

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 113
3. What pharmacotherapeutic alternatives are available to achieve
the new goals?

CHAPTER 36
4. Design a pharmacotherapeutic regimen for this patient’s ulcer
that will accomplish the new treatment goals.
5. How should the PUD therapy you recommended be monitored
for efficacy and adverse effects?
6. What information should be provided to the patient about her
therapy?
7. How should her frequent headaches now be treated?

NSAID-Induced Ulcer Disease

■■ SELF-STUDY ASSIGNMENTS
1. Describe the advantages and limitations of both endoscopic and
nonendoscopic diagnostic tests to detect H. pylori.
2. After performing a literature search on H. pylori eradica-
tion therapy, compare the efficacy of three- and four-drug
regimens.
3. Based on the literature search on H. pylori eradication therapy,
determine whether therapy should be continued for 7–14 days
or provided in a sequential order.

CLINICAL PEARL
Rapid urease breath tests for diagnosis of H. pylori should not
be used for patients who have received bismuth-containing
medications, proton pump inhibitors, or antimicrobials within
the previous 4 weeks due to the increased risk of a false-negative
result.

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