Activity no.

2
SOAP Notes of PUD

Patient Information
Name: Justine Ward
Age: 67 Years
Gender: Female
Medical Record Number: 123-ABC
Date of Visit: 19/02/2024

Subjective
CCs Patient presents with abdominal (Stomach) pain.

HPI Patient reports 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.

PMH CAD with drug-eluting stent placement × 3 months

Hypothyroidism × 22 years
Hyperlipidemia × 10 years
Lactose intolerance × 47 years
Postmenopausal; LMP ~13 years ago

MH Plavix 75 mg PO daily
Lisinopril 5 mg PO daily
Metoprolol tartrate 25 mg PO twice daily
Aspirin 325 mg PO daily
Synthroid 125 mcg PO daily
Atorvastatin 80 mg PO daily
MVI tablet PO daily
Tums 500 mg PO PRN stomach pain
Naproxen sodium 220 mg PO PRN headache (one to two times daily
for the past month)
Lactaid one tablet PO PRN dairy product consumption

Allergies NKDA

SH Married
Drinks one to two glasses of wine most days of the week.

FH Her mother died of lymphoma at the age of 75.

Her father is alive with prostate cancer, AMI and glaucoma at age of 70.
ROS Unremarkable

Objective
VS BP 110/72 left arm (seated),
HR 99,
RR 16 BPM,
Temp. 37.2°C;
Wt. 149.6 lb (68 kg)
Ht 5′3″ (160 cm)

HEENT Normocephalic; PERRLA; EOMI

Physical Slightly overweight woman in moderate distress

Examination Mild epigastric tenderness
Stool heme (+)

Lab Na 142 mEq/L Hgb 10.1 g/dL

Data Ca 9.5 mg/dL 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 CO2 30 mEq/L
WBC 7.6 × 103/mm3 Albumin 5.0 g/dL
BUN 8 mg/dL MCV 72 μm3
TSH 2.4 μU/mL SCr 0.7 mg/dL
Retic 0.4% TC 142 mg/dL
FBG 92 mg/dL Fe 48 mcg/dL
LDL 64 mg/dL HDL 53 mg/dL
TG 127 mg/dL

Diagnostic EGD: 5.5-mm superficial ulcer in the superior duodenum with no

Imaging active bleeding.
Biopsy of duodenal mucosa reveals H. Pylori-like organisms with
inflammation.

Assessment
Provisional PUD with duodenal ulcer and anaemia
Diagnosis (The result of EDG shows the duodenal ulcer. While the biopsy shows the
major cause is H. Pylori infection. And in the lab values the low
haemoglobin, hematocrit, and mean corpuscular volume suggest the
presence of microcytic anaemia).
We can go for the H. pylori eradication antibiotics regimen.
Add Iron supplements to manage anaemic conditions.

Drug-Related Ulcer may induce due to chronic use of NSAIDs (Aspirin + Naproxen).
Problems Remove aspirin and add the misoprostol to the medication plan.
Plan
Medication Plan 1. Triple therapy for 14 days
● Omeprazole 20 mg PO BID
● Clarithromycin 500 mg PO BID
● Amoxicillin 1000 mg PO BID
2. Misoprostol 200 mcg PO daily
3. Ferrous sulphate 65 mg PO TID
4. Plavix 75 mg PO daily
5. Lisinopril 5 mg PO daily
6. Metoprolol tartrate 25 mg PO twice daily
7. Synthroid 125 mcg PO daily
8. Atorvastatin 80 mg PO daily
9. MVI tablet PO daily
10. Tums 500 mg PO PRN stomach pain
11. Naproxen sodium 220 mg PO PRN headache
12. Lactaid one tablet PO PRN dairy product consumption

Non-Pharmacological Use cranberry juice.

Interventions/Patient Limit/Avoid alcohol use.
Education Avoid spicy food.
Adopting behaviours to promote ulcer healing (eating
smaller, more frequent meals).

Follow-Up You should undergo follow-up tests after completion of your

treatment regimen.

Monitoring Check the Lab reports, Physical examination, Patient condition,

Drug ADRs on a regular basis.

Usama Ali
PharmD-8th sem. Student