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    Gerd

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    padma Shrini
    A 58-year-old male patient presented with complaints of heartburn 4-5 times a week for the past 4 months, episodes of regurgitation, and an acidic taste in his mouth. Physical examination and test results confirmed the diagnosis of gastroesophageal reflux disease (GERD). The patient was treated with medications including omeprazole, ranitidine, ferrous fumarate, and sucralfate gel and discharged with medications and lifestyle counseling to manage his GERD.

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    Gerd

    Uploaded by

    padma Shrini
    24 views19 pages
    A 58-year-old male patient presented with complaints of heartburn 4-5 times a week for the past 4 months, episodes of regurgitation, and an acidic taste in his mouth. Physical examination and test results confirmed the diagnosis of gastroesophageal reflux disease (GERD). The patient was treated with medications including omeprazole, ranitidine, ferrous fumarate, and sucralfate gel and discharged with medications and lifestyle counseling to manage his GERD.

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    A 58-year-old male patient presented with complaints of heartburn 4-5 times a week for the past 4 months, episodes of regurgitation, and an acidic taste in his mouth. Physical examination and test results confirmed the diagnosis of gastroesophageal reflux disease (GERD). The patient was treated with medications including omeprazole, ranitidine, ferrous fumarate, and sucralfate gel and discharged with medications and lifestyle counseling to manage his GERD.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    24 views19 pages

    Gerd

    Uploaded by

    padma Shrini
    A 58-year-old male patient presented with complaints of heartburn 4-5 times a week for the past 4 months, episodes of regurgitation, and an acidic taste in his mouth. Physical examination and test results confirmed the diagnosis of gastroesophageal reflux disease (GERD). The patient was treated with medications including omeprazole, ranitidine, ferrous fumarate, and sucralfate gel and discharged with medications and lifestyle counseling to manage his GERD.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 19

    CASE PRESENTATION ON GERD

    19PD18

    1
    CASE SUMMARY

     A 58yrs old male patient was admitted in General Medicine ward with the chief complaints of experiencing
    Heart Burn 4 -5 times a week for last 4 months , Episodes of Regurgitation[ reflux], Acidic taste in his mouth.
    From all the subjective and objective evidence the patient was diagnosed with GASTRO ESOPHAGEAL
    REFLUX DISEASE later treated with medications and discharged.

    2
    SUBJECTIVE EVIDENCE

    DEMOGRAPHIC DETAILS
    NAME MR.X

    AGE 58yrs

    HEIGHT 163cm

    WEIGHT 50kg

    DEPARTMENT GENERAL MEDICINE

    BMI 18.8 kg/m

    3
     CHIEF COMPLAINTS
    Heart burn [4 – 5 times a week ] x last 4 months
    Episodes of Regurgitation [Reflux ]
    Acidic taste in his mouth
     PAST MEDICAL HISTORY
    Nil
     PAST MEDICATION HISTORY
    Nil
     SOCIAL HISTORY
    Alcoholic
    Smoker
     ALLERGY
    Nil
    4
     FAMILY HISTORY
    Nil
    OBJECTIVE EVIDENCE

    VITALS VALUES

    TEMPERATURE 96.8 F

    BLOOD PRESSURE 160/70mmHg

    PULSE RATE 79bpm

    RESPIRATORY RATE 18 cycles/min


    5
    PHYSICAL EXAMINATION

     conscious , Oriented , Afebrile

    PICCLE : Nil

    6
    SYSTEMIC EXAMINATION

     CVS : s1 s2 +
    CNS : NFND
    RS : BLAE +
    GIT :Upper abdomen soft

    7
    TEST VALUES

    RBC 4.26 million cells/cu mm

    WBC 8000 cells/cu mm

    HB 11.2g/dL

    HEMOTOCRIP 40.2%

    MCH 28.6

    MCV 92.9

    SERUM CREATINE 1mg/dL

    SODIUM 135

    POTASSIUM 4.5

    FBS 120mg/dL

    RBS 140mg/dL
    8

    UREA 30
     OTHER TEST
    BARIUM SWALLOW SHOWS GERD

     [ They did not explain the other Investigation properly ]

    BARIUM RADIOGRAPHY : while testing they intake Barium and imaging is done and result in colour
    change and it indicate the presence of erosion.

    9
    ASSESSMENT

     DIAGNOSIS

    From all the SUBJECTIVE and OBJECTIVE evidence the patient was diagnosed with GASTRIC
    ESOPHAGEAL REFLUX DISEASE
    So the patient is in need of
    Proton pump inhibitors
    Antibiotics
    Rehydrants

    10
    PLAN
    S.NO DOSAGE GENERIC BRAND DOSE FREQ ROA DURATIO
    NAME NAME N

    1. TAB OMEPRAZOLE PRILOSEC 20mg BD PO 4 DAYS

    2. TAB RANITIDINE ZANTAC 75mg BD PO 4 DAYS

    3. TAB FERROUS GLOBAC 2mg BD PO 4 DAYS


    FUMERATE
    +FOLIC ACID
    +VIT B12+Zn

    4. SYP SUCRALFATE SUCROFIL 4mg BD PO 4 DAYS


    +OXYDECAINE O GEL
    11
     GOALS OF THERAPY
     To Reduce Heart Burn
     To Reduce Pain
     To Suppress Regurgitation
     Prevent Recurrence

     MONITORING PARAMETERS
     HB level
     Hematocrit

    12
    DISCHARGE SUMMARY

    S.NO DOSAGE GENERIC BRAND DOSE FREQ DURATION


    NAME NAME

    1. TAB OMEPRAZOLE PRILOSEC 20mg BD 7DAYS

    2. TAB RANITIDINE ZANTAC 75mg BD 7DAYS

    3. TAB FERROUS GLOBAC 4mg BD 7DAYS


    FUMERATE
    +FOLIC ACID
    +VIT B12
    4. SYP SUCRALFATE SUCROFIL O 2mg BD 7DAYS
    +OXYTECAINE GEL 13
    PHARMACEUTICAL CARE CAVITY

     DRUG – DRUG INTERACTION


     Nil
     DRUG – FOOD INTERACTION
     Nil

    14
    PHARMACIST INTERVENTION

     INTERACTION : Not found

    THERAPY WITHOUT INDICATION : Nil


    INDICATION WITHOUT THERAPY : Anti emetic , Antacids
    MANAGEMENT : Can proceed with STEP UP THERAPY
    [ LIFE STYLE CHANGES + ALUMINIUM HYDROXIDE + RANITIDINE + OMEPRAZOLE ]
    MEDICATION ERROR :
    SYP. SUCRAFIL O GEL Dose is mentioned as 4mg and the correct dose is 0.102g/ml
    T.GLOBAC is not mentioned whether it is Z (or) XT

    15
    PATIENT COUNSELLING

    DISEASE BASED COUNSELLING

     You are diagnosed with GASTRO OESPHAGEAL REFLUX DISEASE


     It can also be caused due to consumption of Alcohol
     If left untreated it may leads to other complications such as perforation , Rashes , Bloating , Barette’s
    oesophagus ,etc..
     It is an curable Disease
    16
     DRUG BASED COUNSELLING
    Strictly adhere to Medication
    Take SUCRAFIL O GEL with water and shake before use and it should be taken 1hr Before (or) 2hrs After food.
    OMEPRAZOLE should be taken 30mins Before food

    17
    LIFE STYLE MODIFICATION

     Avoid oil foods


     Avoid Meat
     Have small frequent meals
     Avoid consumption of Alcohol
     Avoid Smoking
     Avoid Dehydration

    18
    19

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