FOCUSED NOTE: PEPTIC ULCER DISEASE DUE TO HELYCOBACTER PYLORI.
CHIEF COMPLAINT (C/C)
“I have epigastric pain, heartburn, bloating, and excessive release of gas. The epigastric pain and heartburn are severe when I am hungry and they go away when I eat some food.”
HISTORY OF PRESENT ILLNESS (HPI)
A 38-year-old Latino male patient has visited the clinic unaccompanied. His chief complaint is epigastric pain that occurs together with heartburn, bloating, and excessive release of gas. These symptoms started a year ago. Initially, the used to occur when the patient is hungry but their frequency have increased to about twice a day. According to the patient, the epigastric pain and heartburn are worsened with hunger but they resolve when he eats some food.
They are also triggered when he consumes, fruits, spicy foods, and some beverages such as fresh juice. The patient reports that he had a sprain of the ankle joint about a year ago and that he often uses non-steroidal anti-inflammatory drugs (NSAIDs) to relieve the pain which has never gone away completely. He denies using any other medications apart from NSAIDs.
PAST HISTORY
CHILDHOOD ILLNESSES:
Denies a history of measles, mumps, rubella, whooping cough, rheumatic fever, scarlet fever, or polio.
IMMUNIZATION:
Childhood vaccine
Immunization
– Hepatitis B: 3/3
– Diphtheria, Tetanus, and Pertussis: 5/5
– Booster dose of TDAP 2018
– Hemophilus influenza type B: 4/4
– Pneumococcal conjugate: 4/4
– Inactivated Polio- virus- 4/4
– Measles, Mumps, Rubella: 2/2
-Influenza 01/22
COVID vaccine Completed 10/17/21, 02 /20/22.
ADULT ILLNESS: The patient had malaria last year. He was successfully treated at home without hospitalization because his symptoms did not require hospital admission. He also suffered a sprain on the ankle joint about 12 months ago. He was treated as an outpatient without hospitalization.
PSYCHIATRIC ILLNESS: Reports a history of alcohol use disorder, depression, and anxiety.
ACCIDENTS or INJURIES: Suffered a sprain on the ankle joint about 12 months ago when he was playing soccer.
OPERATIONS: Denies a history of surgery
ALLERGIES: No known drug or food allergies.
MEDICATIONS: Reports NSAIDs use.
COMPLIMENTARY TREATMENTS: None
FAMILY HISTORY: Father is alive and he is currently 70 years old. He is healthy without a serious medical diagnosis. Mother is 66 years old and has not been diagnosed with a serious health condition. The patient is the first born in a family of 2 children. His younger sister is healthy. The patient does not have any information regarding the cause of death of his maternal grandparents. His paternal grandmother has hypertension while his paternal grandfather is healthy.
SOCIAL HISTORY
Education: A diploma graduate
Occupation: Surveyor
Living situation: Lives with his family in a rental house
Denies a history of childhood asthma. Denies a history of hemoptysis, bronchitis, emphysema, pneumonia, tuberculosis, or pleurisy. Does not report TB or exposure to TB. Last physical check-up for pulmonary function was two years ago. Denies a history of pneumonia or a history of exposure to chemicals.
Physical activity: The patient engages in physical activity over the weekends by playing soccer. He decided to reduce the frequency of playing soccer since he suffering an ankle sprain.
CARDIAC: Denies chest pain, or palpitations. Denies paroxysmal nocturnal dyspnea. Does not report orthopnea, edema, palpitations, hypertension, or known heart disease. Denies rheumatic fever, heart murmurs, or pain in posterior calves.
GASTROINTESTINAL: Reports epigastric pain heartburn, bloating, and excessive release of gas. The epigastric pain and heartburn are severe when the patient is hungry and they go away when he eats some food. Consumption of fruits, spicy foods, and some beverages such as fresh juice triggers the epigastric pain and heartburn. Reports dyspepsia or indigestion. Reports getting full quickly whenever he consumes food.
PHYSICAL EXAMINATION
VITAL SIGNS: BP: 128/85 (sitting, automatic), P: 89, RR: 18, T: 36.5 Ht: 62 inches Wt: 172 lbs; BMI: 22.8.
GENERAL SURVEY: Alert and oriented to time, person, and place. No evidence of acute distress or fatigue. Well nourished. The patient’s appearance is appropriate for the stated age. Reports indigestion and nausea.
SKIN: Skin is smooth, warm, dry, and intact without rashes, or lesions. Nail beds are pink with no evidence of clubbing or cyanosis.
HEAD: The head is normocephalic and atraumatic. Hair is short. There is no evidence of hair loss or alopecia. There is no evidence of hair thinning or broken hair shafts. Hair is evenly distributed throughout the scalp. Hair texture is normal.
EYES: Clear conjunctivae on both eyes. Both eyes are symmetrical. Lids are without drooping or ptosis. Both sclerae are white. No evidence of hemorrhage or exudates. No icterus or muddy appearance on the sclerae, conjunctivae are pale, corneal clear, PERRLA, EOM are intact, light reflex direct and consensual brisk and intact. No swellings of lesion on eye lids. Visual acuity 20/20 bilateral. Optic disc with intact red reflex, optic disc with sharp margin, small central cup, and no edema. Retinal vessels intact, no A/V nicking or cotton wool spots.
EARS: Internal and external ears are without edema or tenderness. Both ears are symmetrical and are in line with the outer canthus of the eyes. The pinna can easily be manipulated without difficulties. Rinne test AC>BC. No evidence of obstruction of the ear canals. No evidence of cerumen observed. The tympanic membrane IS pearly grey with good cone of light bilaterally. Weber -midline. Acuity good to whispered voice.
NOSE: Nasal mucosa is moist and pink. No evidence of discharge or nasal congestion. Turbinates are neither boggy nor enlarged. The sinuses are non-tender. The nasal septum is intact and positioned midline.
MOUTH AND THROAT: The buccal mucosa is moist. The tongue is positioned midline, moist, pink, and without fasciculation. The teeth in good arrangements on the gums. No evidence of cavities. The gum is pink with no evidence of gingivitis or halitosis. No tonsils or erythema observed on the throat. No exudates, lesions, or nodules. The pharynx is pink in appearance.
NECK: The trachea is positioned midline. The neck is supple with no adenopathy observed. Thyroid gland is normal without masses. Palpable thyroid isthmus. Carotid pulse 2+ bilaterally without bruit. No jugular vein distention (JVD). No stridor observed.
RESPIRATORY: Normal diaphragmatic excursion. The chest wall is symmetric and without deformity. No tenderness on palpation of anterior and posterior chest. No signs of trauma observed. No evidence of respiratory distress. Clear lung sounds in all lobes of the lungs bilaterally without wheezes, rales, or Ronchi. Normal Resonance on percussion of all lung fields.
CARDIOVASCULAR: The external chest is normal in appearance without palpable lifts, heaves, or thrills. Invisible PMI and is palpated in the 5th intercostal space at the midclavicular line. Normal heart rate and rhythm. No murmurs, rubs, or gallops. S1 and S2 are heard and are of normal intensity. No increase carotid pulsation on inspection; No carotid bruit auscultated; Bilateral carotid upstrokes brisk without bruits. No increase jugular venous pulsations; Heart sound one (S1) and heart sound two (S2)-normal; No S3 or S4; No murmurs, rubs, heaves, or gallops.
ABDOMEN: Abdomen is soft and protuberant, no scars. Normal bowel sounds active in all four quadrants; No abdominal guarding, or tenderness; Percussion notes tympanic in all four quadrants. No shifting dullness. No tenderness on light and deep palpation. Liver, spleen, and kidneys non-palpable. Umbilicus is midline with no evidence of herniation. No abnormal masses observed.
PROBLEM LIST
Epigastric pain
Heart burn
Symptoms being triggered by hunger and consumption of fruits, spicy foods, and some beverages
Symptoms resolve with eating
Epigastric pain and heart burn started about a year ago
Bloating
Indigestion/dyspepsia
Excessive release of gas
Getting full quickly
Use of NSAIDs
ASSESSMENT
Peptic ulcer disease due to Helicobacter pylori
DIFFERENTIAL DIAGNOSIS
Gastroesophageal reflux disease (GERD)
Irritable Bowel Syndrome (IBS)
Cholecystitis
Pancreatitis
DIAGNOSTIC PLAN:
Diagnostics
-Stool monoclonal antigen test
-Urea breath test
-Rapid urease test
-Bacterial culture
-Endoscopy with biopsy
MEDICATION
-Proton pump inhibitors
-1 g of amoxicillin taken twice a day
-500 mg of clarithromycin taken twice a day
REFERRAL:
-No referrals are required at this time
Follow UP in 2 weeks
PATIENT EDUCATION
Your primary diagnosis is peptic ulcer disease caused by a microorganism called Helicobacter pylori. H. pylori is a type of bacteria that is usually found in the stomach. Certain triggers such as continued use of NSAIDs usually affect its normal concentration in the stomach leading to problematic symptoms that manifest as disease. Patients with peptic ulcers due to H. pylori usually present with epigastric pain or severe pain in the upper parts of the abdomen, heartburn, bloating, and excessive release of gas (American College of Gastroenterology, 2022; Hudnall et al., 2022). The abdominal pain is mostly triggered by hunger, fruits, and beverages with high acid content. Eating some food relieves the epigastric pain and heartburn.
Other common symptoms are indigestion, nausea, and vomiting (Narayanan et al., 2020). Your peptic ulcer may be attributed to continued use of NSAIDs which might have triggered the excessive production of H. pylori in the stomach (Kowada & Asaka, 2022). You will be treated with proton pump inhibitors, 1 g of amoxicillin taken twice a day, and 500 mg of clarithromycin taken twice a day (American Academy of Family Physicians, 2020).
You are advised to adhere to the recommended regimen and call the clinic in case you experience problematic symptoms. You are advised to engage in physical activity and consume a diet that is rich in proteins and vegetables. You should limit the consumption of fruits, spicy foods, and beverages with high acid content (Mayo Clinic, 2022). Feel free to reach the clinic using the number provided in your forms if you experiencing problematic symptoms.
References
American Academy of Family Physicians. (2020). Diagnosis and treatment of peptic ulcer disease and H. pylori infection. https://www.aafp.org/afp/2015/0215/p236.html
American College of Gastroenterology. (2022). Peptic ulcer disease. https://gi.org/topics/peptic-ulcer-disease/
Hudnall, A., Bardes, J. M., Coleman, K., Stout, C., Regier, D., Balise, S., Borgstrom, D., & Grabo, D. (2022). The surgical management of complicated peptic ulcer disease: An EAST video presentation. The Journal of Trauma and Acute Care Surgery, doi: 10.1097/TA.0000000000003636.
Kowada, A., & Asaka, M. (2022). Economic and health impacts of Helicobacter pylori eradication strategy for the treatment of peptic ulcer disease: A cost-effectiveness analysis. Helicobacter, 27, e12886. doi: 10.1111/hel.12886.
Narayanan, M., Reddy, K. M., & Marsicano, E. (2020). Peptic ulcer disease and Helicobacter pylori infection. Missouri Medicine, 115(3), 219–224.
Mayo Clinic. (2022). Helicobacter pylori infection. https://www.mayoclinic.org/diseases-conditions/h-pylori/diagnosis-treatment/drc-20356177 |