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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Determine whether patients with diabetes who have risk factors for NSAID-induced ulcer disease should remain on aspirin and at what dose.

  • Identify the hallmark signs and symptoms of NSAID-induced PUD.

  • Recommend appropriate therapy for the treatment of NSAID-induced PUD while taking into account Helicobacter pylori infection and its appropriate diagnosis and follow-up.

  • Recommend alternative therapies besides traditional NSAIDs for treatment of pain and inflammation in patients with PUD.

  • Educate patients effectively on treatment options for NSAID-induced PUD.

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PATIENT PRESENTATION

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Chief Complaint

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“I have had some stomach pain in the last 2 weeks and am worried that my ulcers have come back.”

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HPI

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Tom Jackson is a 55-year-old man who presents to his PCP with complaints of epigastric pain for 2 weeks. He stated that he started taking OTC Zantac for the pain with partial relief, but the symptoms persisted. They are consistent with those he experienced 3 months ago when he was diagnosed empirically with bleeding gastric ulcers. When questioned, he cannot recall what diagnostic tests were done, but he does recall having a prescription for several medications that he did not finish because he felt better after about a week and the medications gave him an odd taste in his mouth. He also says that acetaminophen has failed to provide much symptom relief from his osteoarthritis, so he currently uses a variety of OTC NSAID products. Additional review of his pharmacy records shows that he was prescribed a 14-day course of amoxicillin, clarithromycin, and omeprazole 3 months ago.

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PMH

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  • H/O PUD with H. pylori

  • GERD

  • OA primarily in right wrist and hand but also left hip

  • HTN

  • Type 2 DM

  • S/P appendectomy after appendicitis in the 1980s

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FH

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Father died of MI at age 45; mother died of cervical CA in her eighties

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SH

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Police officer; smokes one to two packs per week down from two packs per day 6 years ago; drinks one alcoholic drink per day but admits to occasionally having more; plays basketball one to two nights per week as he can tolerate with OA symptoms.

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Meds

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  • ASA 325 mg PO once daily

  • Lisinopril 20 mg PO once daily

  • Amlodipine 10 mg PO once daily

  • Metformin 1000 mg PO twice daily

  • Atorvastatin 40 mg PO nightly

  • OTC naproxen 200 mg, two tablets PO one to four times daily for OA pain

  • OTC ranitidine 75 mg, one tablet two to three times daily for stomach pain

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All

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Codeine (rash); tetracycline (rash/hives)

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ROS

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Denies headache or chest pain. Occasional SOB. No heartburn, weakness, polyphagia, polydipsia, or ...

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