Problem
Duodenal ulcer
Desired outcomes of
Detailed assessment
treatment
 Heal ulcer
 Due to naproxen?
 Prevent relapse
 H. pylori status
Action
Follow up and monitoring




Anemia
Correct Hb (
target)



Rheumatoid arthritis
Prevent
relapses
Control
symptoms
Slow
progression of
disease

Reduce symptoms
(shortness of
breath , ankle
swelling )
Reduce hospital
admissions
Prevent premature
mortality



Congestive heart failure




Due to blood loss
from ulcer?
Due to RA?

Appears
controlled at
present
Can patient cope
without NSAID???

Symptoms appear
well controlled at
present
 Is patient's condition
stable ?if so could you
consider adding a
betablocker?
 Number of hospital


Stop naproxen
Oral PPI for 4
weeks
Eradication
therapy if H.pylori
positive
If iron deficient ,
start Ferrous
sulphate
Add ascorbic acid
since also on PPI


If patient can not
cope without
NSAID , restart
once ulcer healed
but add in longterm PPI
 If stable , consider
starting bisoprolol 1.25
mg initially and titrate
slowly
 Consider increasing
dose of lisinopril if Bp
will allow this



Presence of
symptoms
Rescope to confirm
healing
Hb after 2-3
months
 Symptoms of
anemia ( fatigue ,
shortness of
breath)
 Symptom control
 CRP , ESR
 Functioning of
joints
 CBC and LFTs since
on methotrexate (
risk of toxicity as
was on NSAID)
Signs of worsening
oedema ( e.g. ankle
swelling , shortness of
breath)
Pulse , Bp
U
+
Es
( urea and electrolyte
s)
Hypertension

Control Bp , target
< 130/80 mmHg
admissions in last
year?
 Could lisinopril dose
be titrated further?
Bp appears controlled , but is
level lower than normal due
to bleed?
Lisinopril a good choice since
patient also has heart failure



Continue to monitor
Bp
No action required
Weight
Monitor Bp
Monitor urea , Cr , K+