CASE PRESENTATION ON ACID PEPTIC

DISEASE WITH HYPOCHONDRIASIS

AND SECONDARY ANXIETY DISORDER
PRESENTED BY,
UMME HABEEBA A PATHAN
4th PHARM-D
ROLL NO.29
BAPUJI PHARMACY COLLEGE
DAVANGERE.
 SUBJECTIVE

Name : XYZ
Age : 36
Gender : Male
IP No :IP1910150141
Unit : Med. Ⅱ
DOA: 15/10/2019
 REASON FOR ADMISSION

• C/O stiffness of joints since 20 days

• Tingling of upper limbs since 10 days
• Belching
• Chronic headache over occipital area which was throbbing type from
past 2 months
 PATIENT MEDICAL HISTORY : K/C/O hypertension since 20
days

PAST MEDICATION HISTORY : Tab. Amlong (amlodipine) 5mg

1-0-0

SOCIAL HISTORY: Diet- mixed

Sleep- reduced
Appetite- inadequate
 OBJECTIVE
PHYSICAL EXAMINATION
• CNS : Conscious and oriented
• PR : 120bpm
• BP : 120/80 mmHg
• RR : 16 cycles/min
• CVS : S1,S2 heard, no murmer
• Temp : 98.7⁰F
• P/A : Soft, non tender
 LABORATORY INVESTIGATION

HAEMATOLOGY
PARAMETER RESULT NORMAL VALUES

Haemoglobin 15.7g/dl 14-18g/dl

Platelet 2,85,000 cells/ml 1,30,000-4,00,000 cells/cu.mm

WBC 6500cells/cu.mm 4000-11000 cells/ cu.mm

ESR 45mm/hr 0-20mm 1st hour

RBC 5.1 millioncells/cu.mm 4.3-5.9 million cells/ cu.mm

Chloride 108.1 mmol/l 95-105 mEq/l

SGOT 39.3U/L 0-35U/L

SGPT 55.1U/L 0-35U/L

 OTHER INVESTIGATION
The patient was referred to psychiatric department due to psychosomatic
complaints and the PMP assessment was done.
The patient works as an operator in a factory that involves excess chemical
fumes release since 1.5 years
H/O death of four colleagues due to cardiac arrest in past 6 months
Patient takes necessary occupational precautions but perceives excess fear
regarding his health condition
He has increased responsibility at home
Worries regarding his marriage and siblings marriage
Recent death of sister 2.5 years ago
H/O disturbed sleep
Exaggerated sense of responsibility towards work and home
 ASSESSMENT
Based on the subjective, objective and laboratory evidences the patient

was diagnosed with

ACID PEPTIC DISEASE WITH

HYPOCHONDRIASIS AND SECONDARY
ANXIETY DISORDER
 GOALS OF TREATMENT

• To reduce the severity, duration and frequency of anxiety symptoms.

• To improve the functional status.
• To prevent the relapse.
• To improve the quality of life of patient.
 PLAN-DAY 1
BRAND GENERIC NAME CATEGORY DOSE / DAY FREQUENCY
NAME
IVF NS Fluid replenisher 100ml/hour
Inj. Pan Pantoprazole Proton pump inhibitor 40mg 1-0-0
T. Naxdom Naproxen + domperidone NSAID 250mg+10mg 1-0-0
Inj. Ondem Ondansetron Antiemetic 4mg 1-1-1
T. Dolo Paracetamol Antipyretic 650mg SOS
T. Shelcal calcium and vitamin D3 Calcium supplement 500mg 1-0-0
T. Amlong Amlodipine Calcium channel blocker 5mg 1-0-0
T. Migrabeta Propranolol+ flunarizine Vasodilator and cerebral activators 40mg/10mg 1-0-0
plus
T. Eliwel Amitryptiline Tricyclic antidepressant 10mg 0-0-1
T. Daxid Sertraline Serotonin reuptake inhibitor 25mg 1-0-1
T. Clonotril Clonazepam Anti anxiety agent 0.5mg 0-0-1
T. Pronate EZ Etizolam+propranolol Anxiolytic antimigraine 0.5mg/20mg 1-0-0
 DAY-2 DAY-3
PARAMETER Rx PARAMETER Rx
PR-100bpm CST
BP- 130/80mmhg Add otorex ear PR-84bpm CST
c/o ringing sensation in both drops(Benzocaine, chlorobutol,
ears paradichlorobenzene, turpentine
oil) 2 drops 1-1-1 BP- 130/80mmhg

DAY-4 DAY-5
PARAMETER Rx PARAMETER Rx

PR-100bpm CST PR-96bpm CST

BP- 130/80mmhg BP- 130/80mmhg

 DISCHARGE MEDICATION
BRAND NAME GENERIC NAME DOSE FREQUENCY NO. OF DAYS

T. Pan Pantoprazole 40mg 1-0-0 10 days

T. Shelcal Calcium and vitamin D3 500mg 1-0-0 15 days

T. Amlong Amlodipine 5mg 1-0-1 To continue

T. Migrabeta plus Propranolol+ flunarizine 40mg/10mg 1-0-0 10 days

T. Eliwel Amitryptiline 10mg 0-0-1 10 days

Otorex ear drops Benzocaine, chlorobutol, 2drops 1-1-1 10 days
paradichlorobenzene, turpentine oil

T. Daxid Sertralin 25mg 1-0-1 10 days

T. Clonotril Clonazepam 0.5mg 0-0-1 10 days
T. Pronate CZ Etizolam+propranolol 0.5mg/20mg 1-0-0 10 days
T. Neurobion forte Vit. B Complex 0-0-1 15 days

VISIT AFTER 2 WEEKS

 GOALS ACHIEVED
• Anxiety signs and symptoms were reduced
• Patients condition became better
• Patient’s functional status was improved.
 MONITORING PARAMETERS
For disease:
Monitor for the reduction in anxiety symptoms, improvement in functioning and
for side effects.
For drugs:
T. Amitriptyline: Monitor for sodium levels, ECG, monitor for unusual changes
in behaviour
T. Sertraline: Monitor for bone mineral density, sodium levels, weight gain and
bipolar risk factors.
T. Clonazepam: Monitor for blood counts, liver function tests
T. Naproxen: renal function
 PHARMACIST INTERVENTION
DRUG INTERACTION: 3 major drug interactions were found
1) Ondansetron <> Sertraline
Severity: Major
Type: Pharmacodynamic
Mechanism of interaction: Concomittant use of these drugs can result in
serotonin syndrome due to the hyper stimulation of brain stem 5HT1A and 2A
receptors. There is also increased risk of irregular heart rhythm i.e., QT
interval prolongation by blocking the ion channels involved in ventricular de
and repolarisation and prolong action potential duration
Effect: Cardiac disease, electrolyte disturbance, mental status changes,
irritability, hallucination
Management: Avoid co administration of sertraline and ondansetron or
monitor closely for serotonin syndrome.
2) Amitriptyline<> Sertraline
Severity: Major
Type: Pharmacodynamic
Mechanism of interaction: Co administration of amitriptyline with sertraline
increases the plasma concentration of amitriptyline due to inhibition of
CYPD450, the enzyme responsible for metabolic clearance and also has a risk
of serotonin syndrome
Effect: Ventricular arrhythmia, serotonin syndrome
Management: Avoid co administration of amitriptyline and serotonin
3) Ondansetron <> Amitriptyline
Severity: Major
Type: Pharmacodynamic
Mechanism of interaction: Concomittant use of these drugs can result in
increased risk of irregular heart rhythm i.e., QT interval prolongation by
blocking the ion channels involved in ventricular de and repolarisation and
prolong action potential duration
Effect: Cardiac disease, electrolyte disturbance, mental status changes,
irritability, hallucination
Management: Avoid co administration of amitriptyline and ondansetron or
use with caution
 DRUG-FOOD INTERACTION

1) Propranolol <> food

Severity: Moderate
Type: Pharmacodynamic
Mechanism of interaction: The bioavailability of propranolol is enhanced by the food
Management: Take propranolol at same time each day with meals or immediately after
meals to make it easier for body to absorb medication.
2) Sertralin <> Grape juice
Severity: Moderate
Type: Pharmacokinetic
Mechanism of interaction: There is increased plasma concentration of sertraline by
inhibition of CYP450 mediated metabolism resulting in pharmacokinetic alterations
Management: Avoid grape juice
 INTERVENTION:
• When the body gets stressed the electrolyte levels may be imbalanced. In
this case the chloride levels are slightly elevated. Administration of IVF
NS may again increase the chloride levels resulting in hyperchloremia.
• Inj. Ondem and T. Dolo are prescribed without indication even though
there are no complaints of fever and vomiting
• T. Migrabeta plus is usually prescribed for migraine headache. But in this
case it is given for wrong indication.
• No proper diagnostic test was performed to confirm the presence of acid
peptic disease.
 PATIENT COUNSELLING
About disease:
 Anxiety is a feeling of worry nervousness or an uneasy feeling about future and
present events.
 Signs and symptoms include feeling nervous, increased heart beat, decreased sleep,
difficulty to control worries, being tensed etc
 Complications of anxiety may include depression, substance abuse, suicidal thoughts,
social isolation etc
About medication:
 Take pantoprazole one hour before meal.
 Tab. Amitriptylline may have side effects like dizziness, light headedness, nausea,
vomiting.
 Avoid activities which require mental alertness since many of the drugs causes
dizziness and headache.
 Report if there are any serious side effects.
 About life style modification:
• Exercise is the most important practise to start. It stimulates the body to
produce certain endorphins, which are chemicals in the brain
(neurotransmitters) that helps to reduce anxiety.
• Participating in an exercise program can:
✔ Increase self-esteem
✔ Boost self-confidence
✔ Create a sense of empowerment
✔ Enhance social connections and relationships
• Diet: The brain is one of the most metabolically active parts of the body and
needs a steady stream of nutrients to function. A poor diet may not provide the
nutrients necessary to produce neurotransmitters and may provoke symptoms of
anxiety or depression.
• Poor sleep has a strong effect on mood, in part because the neurotransmitters needed to
support mood are replenished with sleep. Thus we need restorative sleep to maintain a
balanced brain and help alleviate depression and anxiety.
• Thoughts and Emotions: Negative attitudes and feelings of helplessness and hopelessness
can upset the body's hormone balance and deplete the brain chemicals required for
feelings of happiness or calm, as well as have a damaging impact on the immune system
and other parts of our body.
• Certain types of mental training, such as meditation or positive thinking, can affect the
perceptions of the world and make to feel calmer, more resilient, and happier.
• Social Support: Strong relationships and social support networks reduce isolation and
loneliness.
• Keep in regular contact with friends and family.
• Consider joining a class or group.
• Get social support from volunteering and feel the satisfaction of helping others!
• Bond with a pet. Physically, having a loved one close calms us and reduces the emotional
stress.