Patient Information

Chief Complaint

52-year-old male with 3-week history of progressive epigastric pain, postprandial discomfort, and heartburn. Pain is burning in quality, radiates to the chest, significantly worse after meals and when lying down. Associated symptoms include early satiety, abdominal bloating, and occasional nausea without vomiting.

History of Present Illness

Patient reports symptoms began approximately 3 weeks ago following a period of increased occupational stress. Initially self-managed with over-the-counter antacids (Tums, Pepto-Bismol) with partial and temporary relief. Pain typically occurs 30-60 minutes after eating, rated 6/10 at worst, and partially relieved by sitting upright.

Denies melena, hematemesis, hematochezia, unintentional weight loss, dysphagia, or odynophagia. Reports occasional alcohol consumption (2-3 drinks per week, socially), denies tobacco use (quit 10 years ago, 15 pack-year history), denies illicit drug use. No recent travel, no sick contacts, no known food allergies.

PMH: Type 2 diabetes mellitus (diagnosed 2018, A1c 7.2% last month), essential hypertension (diagnosed 2015), hyperlipidemia with hypertriglyceridemia, obesity (BMI 32.4 kg/m²), peptic ulcer disease 5 years ago (H. pylori positive, completed triple therapy with documented eradication), GERD (intermittent symptoms, previously on PPI PRN).

Medications (Home)

• Metformin 1000mg PO BID
• Lisinopril 20mg PO daily
• Atorvastatin 40mg PO QHS
• Aspirin 81mg PO daily
• Omeprazole 20mg PO PRN (not taking regularly)

Allergies

Penicillin (rash) - documented 2019  |  NKDA to foods or environmental allergens

Family History

Father: deceased age 71, MI and T2DM. Mother: alive age 76, HTN and hyperlipidemia. Brother: age 48, T2DM. No family history of GI malignancy, IBD, or celiac disease.

Social History

Works as accountant (sedentary occupation, high stress). Married, lives with spouse. Denies tobacco x 10 years. Alcohol: 2-3 drinks/week. Diet: admits to frequent fast food, large portions, late-night eating. Exercise: minimal, walks occasionally.

Physical Examination

Diagnostic Workup

Hospital Course

Patient was admitted for evaluation of dyspeptic symptoms and underwent EGD on hospital day 2. Endoscopy revealed Grade B esophagitis and antral gastritis. Given positive H. pylori stool antigen and history of prior PUD, decision was made to initiate eradication therapy. Patient tolerated procedure well without complications.

Blood pressure remained elevated during admission (140-150s systolic), and decision was made to uptitrate antihypertensive therapy. Patient received dietary counseling from nutrition services regarding GERD diet modifications and diabetic-heart healthy eating patterns. Blood glucose remained well-controlled on home regimen.

Assessment & Plan

• 1. GERD with Grade B esophagitis (K21.0) - Start omeprazole 40mg PO daily (increased from PRN 20mg) for 8 weeks, then reassess. Lifestyle modifications: elevate head of bed 6-8 inches, avoid eating 3 hours before bedtime, avoid trigger foods (caffeine, alcohol, spicy, acidic), weight loss encouraged. Follow-up EGD in 8-12 weeks to document healing.
• 2. H. pylori gastritis (K29.71) - Initiate clarithromycin-based triple therapy: Clarithromycin 500mg BID + Amoxicillin 1g BID + Omeprazole 40mg BID x 14 days. Note: Patient reports penicillin allergy (rash) - discussed with patient, rash was mild and occurred >20 years ago. After shared decision-making, patient agreed to amoxicillin trial with close monitoring. Alternative: Bismuth quadruple therapy if patient declines. Confirm eradication with stool antigen or breath test 4 weeks after completing antibiotics.
• 3. Hypertriglyceridemia (E78.1) - TG 245 mg/dL, elevated. Continue atorvastatin 40mg, reinforce dietary modifications (reduce refined carbohydrates, limit alcohol, increase omega-3 intake). Consider adding fenofibrate or icosapent ethyl if TG remains >200 after lifestyle optimization. Recheck lipid panel in 6 weeks.
• 4. Type 2 Diabetes Mellitus (E11.9) - A1c 7.2%, at goal. Continue metformin 1000mg BID. Reinforce dietary counseling and importance of regular physical activity. Continue home glucose monitoring. Follow-up A1c in 3 months.
• 5. Essential Hypertension (I10) - Suboptimally controlled during admission (140-150s/80-90s). Increase lisinopril from 20mg to 40mg daily. Continue low-sodium diet. Home BP monitoring recommended. Recheck BP at follow-up visit; consider addition of second agent (amlodipine or chlorthalidone) if not at goal.
• 6. Obesity (E66.9) - BMI 32.4 kg/m². Discussed impact on GERD, diabetes, and cardiovascular risk. Referral to nutrition services completed. Encouraged gradual weight loss of 1-2 lbs/week through dietary changes and increased physical activity. Consider GLP-1 agonist if inadequate weight loss with lifestyle measures.
• 7. History of Peptic Ulcer Disease (Z87.11) - Prior H. pylori PUD 5 years ago with documented eradication. Current reinfection requires treatment as above. Counsel on avoiding NSAIDs; if NSAID required, use with PPI prophylaxis.

Discharge Medications

• Omeprazole 40mg PO BID x 14 days (then 40mg daily x 8 weeks) - NEW
• Clarithromycin 500mg PO BID x 14 days - NEW
• Amoxicillin 1000mg PO BID x 14 days - NEW
• Metformin 1000mg PO BID - CONTINUE
• Lisinopril 40mg PO daily - INCREASED from 20mg
• Atorvastatin 40mg PO QHS - CONTINUE
• Aspirin 81mg PO daily - CONTINUE

Discharge Instructions

Activity: Resume normal activities as tolerated. Begin regular walking program (goal 30 minutes, 5 days/week).

Diet: Follow GERD-friendly and diabetic heart-healthy diet as discussed with nutritionist. Avoid: caffeine, alcohol, chocolate, citrus, tomatoes, spicy foods, fatty/fried foods. Eat smaller, more frequent meals. No eating within 3 hours of bedtime.

Follow-up: PCP appointment in 2 weeks for BP check and medication review. GI follow-up in 6-8 weeks for repeat H. pylori testing and EGD scheduling. Call to schedule appointments if not already arranged.

Return Precautions: Return to ED or call 911 immediately if you experience: severe abdominal pain, vomiting blood or coffee-ground material, black tarry stools or blood in stool, chest pain or pressure, shortness of breath, difficulty swallowing, high fever, signs of allergic reaction (rash, swelling, difficulty breathing).

Disposition

Discharged to home in stable condition. Patient verbalized understanding of discharge instructions and medication changes. Prescriptions sent electronically to patient's pharmacy.