Patient Information: 60-year-old, Hispanic, female.

Subjective

Chief complaint: Patient stated, “I have hearburn.”

HPI: Patient is a 60-year-old female who comes to the office referring abdominal pain of two weeks duration that has intensified two days after she has been taking ibuprofen for headache. Pt refers to be a little stressed with headaches, so she has had to take ibuprofen, her abdominal pain worsens on the empty stomach and is lightly relieved with meals.

PMH:

Age/Health Status: 60 years old HTN

Current Medications: 

Chronic Illnesses: TYPE 2 DIABETES, HYPERTENSION

Hospitalizations/Surgeries: None.

Allergies: NKDA.

Vaccination: Up to date. Plan to receive Flu-vaccination today

Family history:

–          Mother: alive, DM II

–          Father: Died due MI

Social history:

Patient works as a nurse

Patient lives in home with mother. No smoking, drugs or alcohol in the house.

Patient does not consume caffeine, and has a healthy regular diet.

Patient reports sleeping 8 hours per night.

ROS

Constitutional symptoms: Denies chills, fever, night sweats, unexplained weight loss or weight gain, no change in the energy level.

Neurologic: Denies syncope, seizures, disorientation, anxiety, inability to concentrate, or difficulty with balance. Patient reports having a headache and dizziness sometimes.

HEENT: Head and neck: Patient reports a headache. Eyes: Patient denies any changes in his vision, eye pain, or discharge. Ears: Patient denies ear pain, ringing in the ears, any discharge or tinnitus. Nose: Patient denies epistaxis, sinus problems, or nasal congestion. Throat: Patient denies sore throat, problems with tooth pain, bleeding gums, hoarseness, or dry mouth.

Cardiovascular: Patient denies any history of heart murmur, chest pain, palpitations, dyspnea, activity intolerance, or edema.

Respiratory:  Patient denies cough. Denies history of respiratory infections, SOB, wheezing, difficulty breathing, and any exposure to secondary smoke.

Gastrointestinal: Patient complains of abdominal pain associated with empty stomach as explained in HPI. Patient denies diarrhea or vomit.

GU: Denies urgency, frequency, dysuria, suprapubic pain, nocturia, incontinence, hematuria, and any history of stones.

Musculoskeletal: Denies back pain, joint pain, swelling, muscle pain or cramps, neck pain or stiffness, changes in ROM. Patient reports being active through the day but reports having a change in the energy level. Patient reports wearing her seatbelt.

Integumentary: Denies itching, urticaria, hives, nail deformities, hair loss, moles, open areas, bruising, and any skin changes. She reports applying sunscreen while outside.

Hematologic: Denies abnormal bleeding or bruising.

Allergies: Denies any history of allergies.

Psychiatric: Patient denies nightmares, mood changes, anxiety, depression, nervousness, insomnia, suicidal thoughts, and exposure to violence, or excessive anger.

Objective

Physical examination:

Constitutional: BP: 130/80mmhg, HR: 84 b/m, Temp: 98.2⁰F, Resp.: 20 resp. /min, SpO2: 99%, Height: 5’8” inches, Weight: 160 lbs. BMI-Percentile: 53%. Pain level: 4-5/10

Appearance: healthy-appearing, well nourished, and well developed.

HEENT: Head: Norm cephalic, atraumatic, symmetric, non-tender. Eyes: Sclera white, conjunctiva pink, extraocular muscles are intact. Pupils are equal, round. Ears: external appearance normal-no lesions, redness, or swelling; on otoscope exam tympanic membranes clear, no redness, fluid, or bulging noted. Hearing is intact.

Nose: normal appearance. No mucous, inflammation, or lesions present, no polyps or masses. Throat: posterior oropharynx no erythematous, without tonsillar edema or exudate, uvula midline. Mucous membranes pink, moist, without ulceration. No lesions present. No ulcers, masses, or exudate present.

Neck: Supple, negative for masses. 1cm palpable left cervical lymph node, mobile non-tender. No JVD, no bruits. Thyroid small and firm midline.

Respiratory: No deformities of the thorax, bilateral and symmetrical move of chest wall expansion during inspiration and expiration. Regular respiratory rate, no retraction noted, no flaring. Lung sounds clear in all lung fields. Respirations even and unlabored. No wheezing or rhonchus or rales noted during auscultation.

Cardiovascular: Regular rate and rhythm without murmur or gallops. No thrills, no split heart sounds, or friction rubs. No peripheral edema. No precordial bulge, no dyspnea on exertion, and cyanosis.

Breast: Breasts are free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin.

Peripheral Pulses: Regular, equal and intact bilateral.

Abdomen:  Abdomen painful to deep palpation, in epigastric zone. Bowell sounds in all 4 quadrants are present and hyperactive. Abdomen is soft, non-tender. No palpable masses, no hepatosplenomegaly.

Integumentary: Skin pink, warm and dry without rash, lesions, or abnormalities noted.

Musculoskeletal: Extremities: symmetric, no edema, no clubbing, no deformity, full ROM (range of motion) in all extremities.

Neurologic: CNS intact (Cranial nerves I-XII). No neurological deficits noted.

Psychiatric: Judgment and insight intact, rate of thoughts normal and logical. Patient is pleasant, calm, and cooperative.

Hematologic: No bruising or abnormal bleeding noted.

Genitourinary: No bladder distention, suprapubic pain, or CVA tenderness. External genitalia reveal normal appearance; skin color is consistent with general pigmentation.

*No evidence of physical and sexual abuse or neglect detected during physical exam.

Assessment

#1 K29.00 Acute Gastritis

Primary Diagnosis

Acute Gastritis: Gastritis is defined as the histologic presence of gastric mucosal inflammation. The broader term gastropathy encompasses lesions characterized by minimal or no inflammation.

Helicobacter pylori infection may cause both an acute and chronic gastritis. Erosive gastritis may occur in response to nonsteroidal anti-inflammatory drugs (NSAIDs)/alcohol use or misuse and to bile reflux into the stomach that may follow previous gastric surgery or cholecystectomy. Stress gastritis, most commonly related to mucosal ischemia seen in critically ill patients, represents a continuum of disease ranging from superficial (erosions) to deep mucosal damage known as stress ulceration. Autoimmune gastritis is a diffuse form of mucosal atrophy characterized by autoantibodies to parietal cells and intrinsic factor resulting in inflammatory infiltration and atrophy of the corpus mucosa. Phlegmons gastritis is a rare but life-threatening infection of the gastric submucosa and muscularis propria seen in immunocompromised patients.

Differential Diagnosis

GERD: is characterized by specific esophageal and extra-esophageal symptoms. H pylori urea breath test is negative. Endoscopy and esophageal histology show esophageal involvement.

Peptic ulcer disease (PUD): Peptic ulcer disease is strongly associated with Helicobacter pylori infection and nonsteroidal anti-inflammatory drug (NSAID). Stool home test may be positive indicating occult GI bleeding. Frank blood in the stool suggests brisk bleeding. Endoscopy shows presence of peptic ulcer.

Gastric lymphoma: Gastric mucosa-associated lymphoid tissue (MALT) lymphoma is strongly associated with H pylori infection. Stool heme test may be positive indicating occult GI bleeding. Endoscopy may show presence of ulcer or nonspecific mucosal abnormalities. Biopsies show histologically abnormal lymph follicle architecture with variable number of blast cells.

Gastric carcinoma: Patient may have suspicious features (e.g., bleeding, anemia, early satiety, unexplained weight loss [>10% body weight], progressive dysphagia, odynophagia, or persistent vomiting). Gastric adenocarcinoma is strongly associated with H pylori infection and chronic gastritis. Endoscopy shows gastric mass or irregular ulcer.

Pancreatitis: an inflammation of pancreas from infection, medications, trauma, genetic defect, or structural abnormality characterized by epigastric pain often with nausea, vomiting, and elevated amylase, lipase.

Plan

Helicobacter pylori urea breath test

Should be considered in all patients <55 years old presenting with dyspepsia without suspicious features suggestive of upper GI malignancy.

This test has >90% sensitivity and 96% specificity for presence of active infection.

It can be used to monitor response to therapy.

Proton-pump inhibitors (PPIs), bismuth, and antibiotics can interfere with the test. It is generally recommended that, in the post-treatment setting, PPIs are withheld for 7 to 14 days and antibiotics and bismuth withheld for at least 28 days prior to use of the urea breath test to assess H pylori eradication. Test will be positive in H pylori infection. Test will be positive in H pylori infection.

H pylori fecal antigen test

A fecal antigen test identifies H pylori antigen in the stool to diagnose active infection.

Both monoclonal and polyclonal assays are available, each with >90% sensitivity and specificity; monoclonal assay has a sensitivity of 96% and specificity of 97%. [37] [38]

It can be used to monitor response to therapy.

Proton-pump inhibitors (PPIs), bismuth, and antibiotics can interfere with the test. [35] It is generally recommended that, in the post-

CBC

Phlegmonous gastritis may present with significant leukocytosis. The result could be variable; may show reduced Hb and Hct and increased MCV in autoimmune gastritis; leukocytosis with left shift in phlegmonous gastritis

Endoscopy

Should be considered in patients age >55 years presenting with dyspeptic symptoms and in all patients presenting with suspicious features suggestive of upper GI malignancy. Consider in patients with symptoms that are refractory to treatment.

Non-pharmacologic therapy:

Reduction of nonsteroidal anti-inflammatory drug (NSAID) and alcohol use

Medication:

First-line treatment options include triple therapy (a proton-pump inhibitor [PPI] plus 2 antibiotics) or quadruple therapy (a PPI plus bismuth plus 2 antibiotics). [4] Eradication in 70% to 80% of patients is reported.

Triple therapy

lansoprazole : 30 mg orally twice daily for 14 days  or omeprazole : 20 mg orally twice daily for 14 days  or esomeprazole : 40 mg orally once daily for 14 days or rabeprazole : 20 mg orally twice daily for 14 days

— AND —

clarithromycin : 500 mg orally twice daily for 14 days

— AND —

amoxicillin : 1000 mg orally twice daily for 14 days or metronidazole : 500 mg orally twice daily for 14 days

–          Educate the caregiver on the importance of assisting to follow-up appointments and well-check exams.

Referrals:

If patient’s condition worsens, abdominal pain does not resolve,  the patient should be evaluated by a  Gastroenterology in an ER.

Follow-up plan:

. Return to clinic if condition worsens or does not resolve.

References

• Li BZ, Threapleton DE, Wang JY, et al. Comparative effectiveness and tolerance of treatments for Helicobacter pylori: systematic review and network meta-analysis. BMJ. 2015
• Ren Q, Yan X, Zhou Y, et al. Periodontal therapy as adjunctive treatment for gastric Helicobacter pylori infection. Cochrane Database Syst Rev. 2016;(2)
• Lee YC, Chiang TH, Chou CK, et al. Association between Helicobacter pylori eradication and gastric cancer incidence: a systematic review and meta-analysis. Gastroenterology. 2016
• Honda M, Hiki N, Nunobe S, et al. Preoperative vs postoperative eradication of Helicobacter pylori in 150 patients with gastric cancer: a randomized controlled trial. J Am Coll Surg. 2015