H. Pylori infection gastritis

   

GI Case Study:

Chief complaint: “I have recurrent H. Pylori infection”. 

HPI: M.C.  a 46-year-old Hispanic female presents to the GI clinic for complaint  of recurrent H. Pylori infection. She was treated about 2 ½ months ago  with H. Pylori triple therapy and failed treatment. She has PMH of  dyspepsia, and GERD. She also indicates that she has noticed that her  symptoms of dyspepsia are worsening for past 2 months. She has  associated her symptoms with nausea, upset stomach with all foods.  Denies associated symptoms of hematochezia, melena, hemoptysis,  abdominal pain, fever, chills, pain or any other symptoms. 

PMH: 

H. Pylori infection gastritis

Diabetes Mellitus, type 2

Surgeries: None

Allergies: NKDA

Vaccination History: Up-to-date

Social history:

High  school graduate, married and no children. He frequently eats out in  restaurants. He drinks one 4-ounce glass of red wine daily. He is a  former smoker that stopped 3 years ago.

Family history:

Both  parents are alive. Father has history of DM type 2, Tinea Pedis. Mother  alive and has history of atopic dermatitis, tinea corporis and tinea  pedis. 

ROS:

Constitutional: Negative for fever. Negative for chills. 

Respiratory: No Shortness of breath. No Orthopnea. 

Cardiovascular: No edema. No palpitations. 

Gastrointestinal: No vomiting. +Dyspepsia. + Nausea. No constipation. No melena. No abdominal pain.

Physical examination:

Vital Signs

Height: 5 feet 5 inches Weight: 140 pounds BMI: 31 obesity, BP 110/70 T 98.0 po P 80 R 22, non-labored

ABDOMEN: No abdominal distention. Nontender. Bowel sounds + x 4 quadrants. No organomegaly. Normal contour; No palpable masses.

Labs day of visit:: Hgb 15.2, Hct 40%, K+ 4.0, Na+137, Serum Creatinine normal 1.0, AST/ALT normal. TSH 3.7 normal, glucose 98 normal

Assessment:

Primary Diagnosis: Recurrent H. Pylori infection gastritis

Secondary Diagnoses: Dyspepsia

Differential Diagnosis: Peptic Ulcer Disease

Previous medication plan: two months ago and failed.

1. Clarithromycin      500 mg po BID for 2 weeks
2. Omeprazole      40 mg po BID for 2 weeks and then po daily.
3. Cipro      500 mg po BID for 2 weeks

Plan: Tests

Pt had EGD done 2 weeks ago that showed H. Pylori positive gastritis in biopsy results. 

Urea breath test 8 weeks after treatment with H. Pylori medications. Pt needs to stop PPI’s 2 weeks prior to Urea Breath test. 

Labs: No new labs are needed.  

Referrals: may refer based on effect of medication therapy given for 2 weeks.

Follow up: return to office in 8 weeks to reevaluate symptoms.

Discuss new therapy guidelines for H. Pylori treatment, and provide patient education.

APA Format

Below is the website for the American  Academy of Gastroenterology Clinical Guidelines (ACG) for the updated  H. Pylori therapy. Feel free to consult other peer-reviewed articles  within 5 years of publication.

http://gi.org/wp-content/uploads/2017/02/ACGManagementofHpyloriGuideline2017.pdf

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