NRNP 6531 iHuman Case Abdominal Pain Week 7
Chief complaint
Abdominal pain
History of Present illness
The patient is a 50-year old male with dyslipidemia and osteoarthritis of the knees who presents with several weeks to months of abdominal pain and dyspepsia. His pain is mainly epigastric. He describes it as burning pain that improves with eating. He has been taking antacids occasionally, which helps a little, but does not completely alleviate the pain. Several months ago he vomited and described black specks in the vomit even though he did not eat anything black. He also describes episodes of black, tarry stools a few months ago that have since resolved. He thought these issues could just go away, but his abdominal pain continued and so he decided to come into the office. He drinks seven to ten beers per week and has a 30-pack-year smoking history. He takes aspirin for primary cardiovascular disease prevention and takes ibuprofen daily for knee pain. He has no personal or family history of bleeding disorders. There has been no recent travel. He denies dysphagia or odynophagia. There is no early satiety, no diarrhea or constipation, no bloating or increased abdominal girth, and no rectal pain or fecal urgency. The patient denies chest pain, or shortness of breath, lightheadedness, syncope, or dizziness. He has not had any fevers or chills.
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Case Findings
- Burning epigastric pain x several months, improved with eating
- History of coffee-ground emesis
- History o black, tarry stool
- NSAID use
- Moderate alcohol use
- 30-pack-year smoking history
- Epigastric tenderness to palpation
Case Problem Statement
The patient is a 50-year old male presenting for evaluation of several months history of burning epigastric pain that improves with meals and dyspepsia. He also reports a history of coffee ground vomitus and black tarry stools that self-resolved months ago. PMH is significant for knee osteoarthritis (OA) dyslipidemia, OTC use of baby aspirin daily, OTC ibuprofen use PRN for OA pain, and TC antacids use. Social history reveals moderate consumption of alcohol (7-10 beers weekly) and 30-pack year smoking history. On physical exam, there’s moderate epigastric tenderness to deep palpation and fecal occult blood test (FOBT) is negative.
Primary Diagnosis with coding
Primary diagnosis with ICD-10 code
Peptic ulcer disease (PUD), unspecified ICD-10:K27.0
Rationale for primary diagnosis
Patient reports history of burning epigastric pain relieved with meals. He has a history of coffee ground emesis and black tarry stools. His PMH history reveals several risk factors for PUD; long-term NSAID (ibuprofen) and aspirin use. Social history further reveals multiple risk factors of PUD; moderate alcohol consumption (7-10 beers every week) and 30-pack years of tobacco smoking. A physical exam finding of epigastric tenderness on deep palpation and a positive diagnostic finding of helicobacter pylori further support this diagnosis (Chey et al., 2024).
Include CPT code/s for office visit, preventive exam or procedures performed during this visit.
- CPT Code for Office Visit: 99214
- CPT Code for procedure: include 87338 (Stool Antigen Test – H. pylori), 85025 (Complete Blood Count), & 80053(Comprehensive Metabolic Panel).
Evidence-based guidelines
I am managing a patient diagnosed with peptic ulcer disease (PUD) according to the recommendations provided by the 2024 American College of Gastroenterology (ACG) clinical management guidelines. Once a PUD diagnosis has been established through history, physical exam and H. pylori testing, treatment for H. pylori positive ulcers should be initiated for eradication with a 10 -14 day triple therapy comprising of a proton-pump inhibitor such as omeprazole, and two antibiotics; amoxicillin and clarithromycin. If the patient has a penicillin allergy, metronidazole is recommended. Clinicians should also recommend lifestyle changes including dietary modification, smoking cessation, alcohol avoidance, weight, and stress management. Non-pharmacological management with probiotics, endoscopic therapy, and switching or discontinuing drugs likely to exacerbate PUD and avoiding NSAIDs is crucial to prevent further formation of an ulcer.
Management Plan: Medications, nonpharmacological treatment, ancillary tests, and referrals
Medications
- Stop ibuprofen
- Omeprazole 20mg PO BID – omeprazole is a proton pump inhibitor which reduces gastric acid by blocking the H⁺/K⁺ ATPase pumps to prevent further irritation and promote ulcer healing (Chey et al., 2024). Side effects to watch out for include; nausea, vomiting, headache, increases risk of bone fractures.
- Clarithromycin 500mg PO BID – this is a macrolide antibiotic that binds to the 50S subunit of the H. Pylori ribosome to stop production of essential proteins. This stops H. pylori from growing, reproducing and surviving (Chey et al., 2024). It causes a metallic bitter taste in the mouth, stomach pain diarrhea, nausea and vomiting.
- Amoxicillin 1gm PO BID- this is a penicillin antibiotic that damages the cell walls of H. pylori hence eliminating from the stomach (Chey et al., 2024). Its side effects include an upset stomach, diarrhea, and a rash (if allergic).
Nonpharmacological treatment/supportive care
- Stop alcohol consumption to safeguard the GI tract and improve outcome.
- Quit smoking; tobacco delays healing, increases gastric acid and increases the risk of recurrence (Chey et al., 2024).
- Avoid consumption of spicy foods, caffeine, fried or fatty foods, or chocolates as they are gastric irritants (Chey et al., 2024).
- Eat frequent small meals to prevent the buildup of acid.
- Embrace more effective stress management techniques such as mindfulness yoga, and deep breathing since stress can trigger flare-ups and worsen symptoms.
Any ancillary testing needed
- Endoscopy to evaluate for gastric cancer and monitor ulcer healing.
Referrals
- For free smoking cessation services contact Kick It California by calling 1-800-300-8086 to engage a coach.
- Gastroenterology consult for further evaluation and management
- Nutrition consult for dietary evaluation and management
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SDOH, health promotion and risk factors
SDOH
- Economic stability – salesman for a tech company
- Education access and quality- patient makes poor health choices (smoking & alcohol) that negatively impact his health.
- Healthcare access and quality – last routine exam was 2 years ago. No issues with regular dental & vision appointments. Uptodate with immunizations.
- Neighborhood and environment- married & lives with wife
- Social and community domains – wife & two adult children (now out of the house).
Health promotion
- Remember to get your annual influenza immunization as it reduces the risk of severe flu and possible hospitalization.
- Consider screening for lung cancer since early detection improves survival among high-risk individuals.
- Every 1-2 years, always have a blood pressure check. Blood pressure is a silent killer and risk factor for kidney & cardiovascular disease and stroke.
- Consider annual diabetes screening to allow timely intervention and prevent complications
- Prostate cancer is common in men aged 50 years and older. Consider screening every 2 years for early detection and intervention before it spreads.
Risk factors
This patient’s risk factors for PUD include long-term use of OTC NSAIDs (ibuprofen), OTC baby aspirin, chronic tobacco smoker (30-pack years) and moderate alcohol consumption (7-10 beers weekly).
Patient Education
- You have been diagnosed with peptic ulcer disease (PUD). This is a condition primarily caused by helicobacter pylori which causes a discontinuation of the inner GI tract lining (Chey et al., 2024). Patients with PUD often report a burning epigastric pain that occurs 2-3 hours after a meal (duodenal ulcer) or shortly after a meal (gastric ulcer).
- Peptic ulcer disease can also be caused by NSAIDs which increase production of bicarbonate, decrease gastric mucus and decrease blood flow in the gastric mucosa. Excessive alcohol consumption and tobacco smoking are also primary causes.
- The clinical presentation of PUD varies with age and location of the disease. Commonly, patients often report symptoms such as abdominal fullness, epigastric abdominal pain, melena, bloating, weight gain/weight loss, nausea, hematemesis, or coffee ground vomit (Chey et al., 2024).
- Management of PUD requires a combination of pharmacological and non-pharmacological interventions. The recommended first-line agent is a bismuth-quadruple drug regimen with lifestyle changes and continuous monitoring.
- To have a completely healed ulcer, take the medications as prescribed. Do not skip a dose.
- Smoking weakens the gastric lining and increases your risk to PUD. Quitting is important to promote healing and recovery (Chey et al., 2024).
- Aspirin & ibuprofen increase the risk of internal bleeding and irritate the gastric lining which contributes to the development of ulcers (Chey et al., 2024). You can use a safer option such as acetaminophen rather than ibuprofen.
- OTC drugs can lead to drug-drug interactions with adverse reactions. Do not buy an OTC medication without input of a licensed provider, and always inform your PCP of the drugs you are taking including supplements and OTC medications.
- Alcohol delays the healing of an ulcer, exacerbates the risk of bleeding and causes liver damage (Chey et al., 2024). Reduce intake gradually and stay away from people or situations that encourage drinking.
Follow up
- Return to this clinic in 6 weeks for an endoscopy to ascertain healing of the ulcer and a repeat H. pylori for a test of cure that confirms eradication
- Seek urgent care if you vomit blood, experience dizziness/fainting, a rapid heart rate, or severe abdominal pain.
References
Chey, W. D., Howden, C. W., Moss, S. F., Morgan, D. R., Greer, K. B., Grover, S., & Shah, S. C. (2024). ACG clinical guideline: treatment of Helicobacter pylori infection. Official journal of the American College of Gastroenterology| ACG, 119(9), 1730-1753. https://doi.org/10.14309/ajg.0000000000002968
Conti, C. B., Agnesi, S., Scaravaglio, M., Masseria, P., Dinelli, M. E., Oldani, M., & Uggeri, F. (2023). Early gastric cancer: update on prevention, diagnosis and treatment. International journal of environmental research and public health, 20(3), 2149. https://doi.org/10.3390/ijerph20032149
Katz, P. O., Dunbar, K. B., Schnoll-Sussman, F. H., Greer, K. B., Yadlapati, R., & Spechler, S. J. (2022). ACG clinical guideline for the diagnosis and management of gastroesophageal reflux disease. Official journal of the American College of Gastroenterology| ACG, 117(1), 27-56. https://doi.org/10.14309/ajg.0000000000001538
Szatmary, P., Grammatikopoulos, T., Cai, W., Huang, W., Mukherjee, R., Halloran, C., & Sutton, R. (2022). Acute pancreatitis: diagnosis and treatment. Drugs, 82(12), 1251-1276. https://doi.org/10.1007/s40265-022-01766-4
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