Nu636PUDPeerResponse#2

Mrs. B is a 62-year-old white female who presents to your office with her daughter for follow-up after a recent Urgent Care visit.

• The daughter reports Mrs. B is demonstrating signs of dementia.
• Her daughter notes that the patient has not been eating much for the past few weeks reporting she has a gnawing pain in her stomach.  If she does eat, she reports getting ‘full’ very quickly.  She reports feeling mildly nauseous for the last few weeks.
• The patient sustained a fall injury about 9 months ago from a ladder.  She shattered some teeth and developed an infection.  She is under the care of an oral surgeon.
• The patient’s coworkers have mentioned to the daughter that ‘she is never in her office or available’ over the last few weeks and seems ‘off her game’.
• She was evaluated yesterday at Urgent Care and instructed to follow-up in your office today.
• Labs drawn at Urgent Care reveal a Hgb of 8 and HCT of 24.

Subjective

Mrs. B’s (the patient) daughter reports that Mrs. B is demonstrating signs of dementia. She has had a decreased appetite for a few weeks, and she gets full quickly with meals. The patient complained of gnawing pain in the stomach. She is also complaining of being nauseous for the last few weeks. Mrs. B has had some noted differences in behavior at work. Her co-worker states that “she is never in her office or available” and has been “off her game” for the past few weeks.

Objective

Mrs. B, a 62-year-old white female, is in the office for a follow-up after an urgent care visit. Has a history of a fall injury nine months ago that resulted in some shattered teeth and developing an infection. She is under the care of an oral surgeon. Labs at Urgent Care resulted in a hemoglobin (Hgb) of 8 and a hematocrit (HCT) of 24.

Assessment

The patient’s symptoms of decreased appetite, gnawing pain in the stomach, nausea, and feeling full “quickly” with meals suggest that she possibly has peptic ulcer disease. These same symptoms can be associated with a duodenal ulcer. A patient with a duodenal ulcer most commonly has nocturnal pain (Malik et al., 2023). She has a hemoglobin of 8 and a hematocrit of 24, suggesting that this patient is anemic. According to her hemoglobin of 8, the National Cancer Institute grades this as moderate anemia (Badireddy & Baradhi, 2023). Anemia could also account for this patient’s cognitive impairment that makes her daughter believe she has dementia, and her not being herself at work.

Plan

There is a need to differentiate if this patient has peptic ulcer disease or a duodenal ulcer. I need to know more about the symptom’s onset, location, duration, characteristics, aggravating/alleviating factors, radiation/ relieving factors, timing, and severity. A medication history is also needed to rule out any medication being a possible cause of peptic ulcer disease. The most accurate test is an esophagogastroduodenoscopy (EGD) or a barium swallow if there is any contraindication (Malik et al., 2023). She needs complete blood work, a liver function panel, and to have amylase and lipase levels evaluated (Malik et al., 2023). She should also be checked for Helicobacter pylori (H pylori) by serology testing or a urea breath test (Malik et al., 2023).

A complete blood count needs to be collected to check for anemia, including hemoglobin, hematocrit, mean corpuscular volume (MCV), and a reticulocyte count index (Badireddy & Baradhi, 2023). A comprehensive metabolic panel, serum iron studies, serum vitamin B12, folic acid, thyroid stimulating hormone, and stool for occult blood should also be collected for this patient (Badireddy & Baradhi, 2023).  

• Therapeutics

I will treat this patient for peptic ulcer disease based on the cause, how it presents, and complications. If she has this issue from H. pylori, I will treat her with triple therapy. This includes a proton pump inhibitor like Pantoprazole twice daily, Amoxicillin 1 gram twice daily, and Clarithromycin 500mg twice daily (Arcangelo et al., 2021, p. 532). This combination is given for 7-14. If not caused by H. pylori, treatment includes antacids, H2 receptor antagonists, proton pump inhibitors, and bismuth subsalicylate (Arcangelo et al., 2021, p. 528).

I would like to treat this patient’s anemia with oral iron because her hemoglobin level is 8. Treatment does not require transfusion until the hemoglobin level is less than 7 (Badireddy & Baradhi, 2023). If lab work shows that she has a vitamin B12 and folic acid deficiency, I will treat her with supplements of B12 and folic acid (Badireddy & Baradhi, 2023).

• Educational

She needs to be educated on the possible side effects of her prescribed medication and the possibility of interactions with other medicines to treat both peptic ulcers and anemia. Nutritional and lifestyle changes need to be considered in patients with peptic ulcers. Teach her about avoiding foods, eating smaller meals, and not lying down for at least 3 hours post-meal (Arcangelo et al., 2021, p. 535). This patient should also avoid peppermint because it can cause ulcer formation (Arcangelo et al., 2021, p. 535).

To educate the patient concerning anemia, she must be taught about the importance of adherence to therapy and the possible side effects of prescribed medication (Arcangelo et al., 2021, p. 1028). Encourage consumption of fortified foods or supplements (Arcangelo et al., 2021, p. 1028). Also, stress that adverse effects must be reported (Arcangelo et al., 2021, p. 1028).

• Consultation/Collaboration

Collaboration for peptic ulcer disease possibly includes gastroenterology, a pharmacist, and a dietary consultant (Malik et al., 2023). Collaboration concerning anemia includes gastroenterology, nephrology, and hematology.

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