CC: abdominal pain and forgetfulness
HPI: 62yo white female presents to the clinic with her daughter. The daughter reports that Mrs. B is demonstrating signs of dementia and has reported coworkers feel she is unavailable or â€œoff her game.â€ The patient has not been eating much for the past few weeks due to a gnawing pain in her stomach. Patient reports that if she does eat, she gets â€˜fullâ€™ very quickly. Patient reports mild nausea for last few weeks. Patient also sustained a fall 9 months ago from a ladder, shattered some teeth and developed an infection in which she is under the care of an oral surgeon. She was evaluated yesterday at Urgent Care and was told to follow-up in clinic today. Labs drawn at Urgent care yesterday were Hgb 8 and HCT 24.
PMH: dementia, fall from ladder 9 months ago and shattered teeth
Allergies: Information not given in case study.
Medications: Information not given in case study
Social History: Has a job. Other SH unknown.
Family History: has a daughter, other FH unknown.
Health Promotion and Maintenance: Information not given in case study.
ENT: fall from ladder caused shattered teeth
Gastrointestinal: Not been eating much past few weeks due to a gnawing pain in her stomach. If she does eat, she gets â€˜fullâ€™ very quickly. Reports mild nausea for last few weeks.
Neurological: patientâ€™s daughter reports she has dementia.
Other ROS not given in case study.
No information given in case study
A: Assessment and Diagnosis
Peptic Ulcer Disease
Differential Diagnoses: GI bleed, NSAID induced gastritis, Anemia (iron deficiency anemia or vitamin B12 anemia), GERD,
- Complete Blood Count (PRIORITY)
- The patientâ€™s blood needs to be drawn to confirm the hemoglobin of 8 and hematocrit of 24. These labs are alarming and if the patient is experiencing forgetfulness and signs of dementia, this can be indicative of an internal bleed somewhere, especially due to her probable peptic ulcer disease (PUD).
- Serum B12 assay
- This would confirm if the patient has a vitamin B12 deficiency which might explain her anemia.
- Ferritin lab test
- This would confirm if the patient has iron deficiency anemia.
- Endoscopy to confirm ulcer and/or GI bleed. If there is an active bleed in the GI system, an epinephrine injection, electro-cauterization, or clipping of the bleeding vessels might be warranted (Siddiqui et al., 2023)
- Maybe a stool occult test
- This would confirm bleeding in the GI system that has a very quick turn-around time.
- Maybe an ultrasound or CT to rule out internal bleed (for unstable patient).
- Maybe a urease breath test that would confirm an H. pylori infection related to PUD. This is the most common noninvasive diagnostic tool for PUD (Arcangelo et al., 2021).
The biggest thing I notice with this patient is that her hemoglobin is 8, her hematocrit is 24 and she is experiencing neurologic deterioration which are severe symptoms that can be indicative of something bigger going on here. I donâ€™t exactly know what could be going on, but I feel like this patient most likely has a stress ulcer due to previous trauma and GI symptoms. I believe this ulcer might be turning into a GI bleed or a worsening anemia because of her poor labs. In order to confirm this diagnosis, I would ask more questions about her bowel patterns, energy levels, types of food she eats, what has been going on recently in her life that might be stressful, etc. I would need to ask questions to rule out certain diagnoses and pay attention to the pertinent negative responses.
Omeprazole PO 20mg once daily (can increase to 40mg/day if needed)
Famotidine PO 20mg once daily (can increase to 40mg/day if needed)
Sucralfate PO 1g 4 times a day
If the patient has a PUD due to stress, the patient might need a PPI or H2Ra like Omeprazole and Famotidine respectively. The Omeprazole should be taken 30-60 minutes before a meal and should not be chewed or split if they are delayed-release tablets. Sucralfate forms an adhesive, viscous substance that attaches to the ulcer and protects it from acid and other gastric content (Arcangelo et al., 2021).
Additionally, if other labs confirm the patient indeed has a low hemoglobin and hematocrit, I might consider consulting with a hospitalist to see if the patient needs a blood transfusion. More about this in the consult/ collaboration section.
The patient should be educated on Peptic Ulcer Disease (PUD) and how to prevent ulcers. The patient may be able to take the PPI and H2RA to prevent ulcers from forming. The patient should be educated on stress-reducing techniques like meditation, exercise, guided imagery therapy, or music therapy to help prevent stress ulcers. When the patient is stressed, there is excess acid in the system and the protect layer of mucus in the stomach is broken down, making it more susceptible to damage and the formation of an ulcer (Siddiqui et al., 2023). The patient would benefit on a little bit of education on what foods make stress ulcers worse and when to take her medication in relation to when she eats.
The patient should also be educated on signs and symptoms of anemia which include fatigue, confusion, headaches, problems concentrating, irritability, loss of appetite, and tingling in peripheral extremities (Freeman et al., 2023).
Lastly, the patient should be educated on when to seek emergency care or follow up which include signs and symptoms of acute anemia/ blood loss, blood in emesis or stool, or any deteriorating symptoms.
I would initially consult with another provider that is available about the patientâ€™s very low hemoglobin and hematocrit to see if the patient would need a blood transfusion. Depending on the facility protocol, the patient might warrant admittance to the hospital for a blood transfusion to stabilize her hemoglobin. If that is not the case, I would ask the provider to confirm what tests and labs might be absolutely necessary to ensure this patient does not have a GI bleed. If that provider believes the patient is stable for treatment of her stress ulcer, I would be able to treat her with the PPI, H2RA, and sucralfate as well as the nonpharmacologic treatment.