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David Deng

Name: Felicia Miller

Age: 39

CC: I have had bad abdominal pain for the last 3 weeks, not

been able to eat, and have had some black tarry stools

HPI:

Mrs. Felicia Miller is a 39 y/o African-American female with a PMH of gastroesophageal

reflux and chronic H. pylori colonization. She presented to the infectious disease clinic with

diffuse abdominal pain without radiation for the last 3 weeks that feels like someone is holding

my belly and not letting go. The pain comes on about 20 minutes after eating, and is not

relieved by a bowel movement or anything else. Because of this, she has been on a liquid diet at

home for the last couple of days; she has been smoking more cigarettes lately to suppress her

appetite. She states she gets nausea and vomiting after eating as well. She also developed black

tarry stools the last couple of days along with loose stools. Mrs. Miller has had a chronic H.

pylori colonization for about 3 years; she just finished her last H. pylori regiment about a week

ago.

PMH

Mrs. Millers other past medical history includes hypertension, osteoarthritis and rheumatoid

arthritis, gastric ulcers, depression, anxiety, fibromyalgia, hiatal hernia, and interstitial cystitis.

Her surgical history includes cholecystectomy, hysterectomy, bladder surgery, dilation and

curettage, missed abortion.

She does not have a primary care doctor.

Her allergies include amoxicillin, duloxetine, valsartan, glycerol, meclizine, tomatoes, diazepam,

hydrocodone/paracetamol, wheat, sertraline.

Active Ongoing Problems

1. H. pylori infection Mrs. Miller has had an H. pylori infection for about 3 years despite 3

different treatment regiments.

a. Just finished a regiment of omeprazole 40 mg BID, clarithromycin 500 mg BID,

metronidazole 500 mg BID. On Omeprazole 20 mg BID currently.

2. Fibromyalgiaa. Currently on gabapentin 900 mg PO TID, tramadol 50 mg PRN pain

3. Hypertension

a. Currently on hydrochlorothiazide-triamterene 50 mg-75 mg PO QDay,

amlodipine 5 mg PO Qday, pravastatin 40 mg QDay

4. Depression

a. Currently on citalopram 20 mg PO QDay

5. Constipation

Place: MCG

Admission: 11/5/2015

Date of Exam: 11/5/2015

Attending: Hatzigeorgiou

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a. Currently on docusate 50 mg PO BID PRN constipation

6. Interstitial cystitis

a. Currently on Pentosan polysulfate 100 mg TID

7. Urge incontinence

a. Currently on oxybutynin 5 mg QDay

8. Allergies anaphylactic prophylaxisa. Currently has epinephrine 0.3 mg IM

Social History:

Mrs. Miller is currently unemployed, on disability. Highest level of education received is a GED.

She lives with her mother here in Augusta. She has no children, is married and separated. She

smokes half a pack a day for about 20 years. She denies alcohol or illicit drug use. She does not

exercise. Currently not sexually active. She states her diet mainly consists of salads and baked

chicken; she states that she does a good job of staying away from wheat and greasy foods.

Immunizations Inactivated influenza vaccine 12/4/2010, PPSV23 12/4/2010

Family History

Sister arthritis, HTN, heart attack

Dad bleeding disorder, diabetes, poor circulation, hearing problem, HTN, arthritis

Mother HTN, bleeding disorder, ovarian cancer, gastric cancer

Brother sickle cell anemia, asthma

Grandparent stroke, cancer, seizures, arthritis, HTN, diabetes, glaucoma

Aunt breast cancer

REVIEW OF SYSTEMS

General: no fevers, no chills, no weight loss, no fatigue, no night sweats, no trouble sleepingSkin/hair/nails: no rashes, itching, or irritation

Eyes: denies diplopia, blurry vision, visual changes

Ears: no tinnitus, no hearing loss, no vertigo

Nose: no change in sense of smell, no increased frequency of colds, no postnasal discharge, no

sinus pain

Mouth and Throat: no bleeding gums, no sores in the mouth, no sore throat, states she has good

dental hygiene

Endocrine: no increased tendency to bleed, no heat or cold intolerance, no polydipsia, no

polyuria

Neck: no lumps or pain

Respiratory: no dyspnea, no cough, no hemoptysis, no wheezing

Cardiac: no palpitations, denies edema, claudication, orthopnea

Gastrointestinal: constipation, no heartburn, no dysphagia, no hematemesis, see PMH

Genitourinary: no changes in urination, no hematuria or discharge,

Musculoskeletal: see PMH

Neurological: no headache, no dizziness, denies seizures, denies syncope, denies loss of

sensation, denies memory loss, no head injuries

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Psychiatric: PMH depression, denies manic episode, no anxiety, no feelings of hurting herself or

others, no auditory or visual hallucinations

Physical Exam:

Vitals: Temp: 36.8oC HR: 55 RR: 16 BP 167/98 O2Saturation: 100%

General: Alert and oriented to person, place, time, and situation, no acute distress

Skin: No skin lesions, warm

Eyes: Pupils equal, round, and reactive to light and accommodation, extraocular movements

intact, normal conjunctiva, visual acuity within normal limits

Head/Ear/Nose/Throat: Normocephalic, normal hearing, nares patent bilaterally, no sinus

tenderness, neck supple and non tender, no lymphadenopathy

Respiratory: Respirations non-labored, breath sounds equal, no wheezes, crackles, or rales,

symmetrical expansion,

Cardiovascular: Normal rate, regular rhythm, no murmur, no gallop, no JVD, point of maximal

impulse midclavicular line fifth intercostal space, 3+ pulses radial, tibialis posterior, dorsalis

pedis, no carotid bruit

Abdomen: soft, normal bowel sounds heard, diffusely tender throughout to light and deep

palpation without rebound or guarding, spleen and liver not able to be palpated, no costovertebral

tenderness

Musculoskeletal: normal range of motion throughout, motor strength 5/5 groups

Neuro: CN II-XII grossly intact, intact to pin prick/vibration/temperature in upper and lower

extremities,

Initial Labs:

LABS:Glucose: 71 mg/dL

BUN: 7 mg/dL L

Creatinine: 0.57 mg/dL L

Na: 137 mEq/L

K: 3.9 mEq/L

Cl: 107 mEq/L

CO2: 20 mEq/L

Ca2+: 9.4 mg/dL

Total protein: 7.1 g/dL

Albumin Lvl: 4.0 g/dL

AST/SGOT: 24 U/L

ALT/SGPT: 37 U/L

Alkaline Phosphatase: 94 U/L

Total bilirubin: 0.4 mg/dL

CBC and Diff

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RBC 4.46 million

WBC 8.6 thous/mm3

HGB 13.7 g/dL

HCT 42.0%

MCV 94.2 fL

MCH 30.6 pgMCHC 32.5 g/dL

RDW 14.2%

PLT 181 thous/mm3

MPV 11.2 fL

Abdominal X-ray done 11/5/15 was completely benign; it showed no evidence of dilated bowel,

no soft tissue mass, organomegaly, calcification, or gas.

EKG not done this visit.

Assessment & Plan

Summary: Mrs. Miller is a 39 year old African American female with a past medical history of

hypertension, osteoarthritis and rheumatoid arthritis, gastric ulcers, depression, anxiety,

fibromyalgia, hiatal hernia, and interstitial cystitis who comes in with a diffuse abdominal pain

associated with anorexia and melena.

Problems

1. Abdominal pain

a. DDx

i. Peptic ulcer diseaseii. Irritable Bowel syndrome

iii. C. difficile infection

iv. Early Crohns disease

v. Early Ulcerative Colitis

vi. Gastroenteritis

vii. Diverticulosis

viii. Celiac disease

b. DX Plan

i. Fetal occult blood test

ii. Stool sample and culture, look for ova and

iii. Patient had a recent esophagogastroduodenoscopy and colonoscopyiv. GI consulted

c. RX Plan

i. Metronidazole 500 mg PO Q8 hours

ii. Pantoprazole 40 mg IV BID

iii. Continue other home peds

2. Fibromyalgia

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a. Continue on gabapentin 900 mg PO TID, tramadol 50 mg PRN pain

3. Hypertension

a. Continue on hydrochlorothiazide-triamterene 50 mg-75 mg PO QDay, amlodipine

5 mg PO Qday, pravastatin 40 mg QDay

4. Depression

a. Continue on citalopram 20 mg PO QDay5. Constipation

a. Continue on docusate 50 mg PO BID PRN constipation

6. Interstitial cystitis

a. Continue on Pentosan polysulfate 100 mg TID

7. Urge incontinence

a. Continue on oxybutynin 5 mg QDay

1) Abdominal pain/anorexia/melena Diagnostic & Therapeutic Problem

Mrs. Miller has diffuse abdominal pain associated with anorexia and pain after eating, nausea

and vomiting after eating, and recent episodes of melena and loose stools. The list of differentials

is quite long, with peptic ulcer disease, irritable bowel syndrome, C. difficile infection, Crohns

disease, ulcerative colitis, gastroenteritis, diverticulosis, and celiac disease. Although peptic ulcer

disease is consistent with the chronic H. pylori colonization, pain after eating, and anorexia, Mrs.

Miller had an EGD done about 5 weeks ago that was normal except biopsies taken showed

continued H. pylori colonization. She did not show for her follow up urea breath test. Peptic

ulcer disease remains a high possibility for the cause of this pain, but the urea breath test should

be performed as well as a repeat EGD. Irritable bowel syndrome is in the differential because of

the patients history of fibromyalgia and depression, but she does not feel relief after a bowelmovement, which excludes this from the diagnosis. C. difficile infection may have occurred after

the patients extensive use of antibiotics for her chronic H. pylori infection, but she does not have

an elevated white count or fever; assaying for C. difficile toxin in the stool will tell if this is the

potential problem; she will be started on metronidazole empirically. Ulcerative colitis, Crohns

disease, and diverticulosis are possible but less likely with a benign x-ray and recent benign

colonoscopy. The patient may have celiac disease, but not likely that it is causing the patients

symptoms because she states that she stays away from wheat.

Because the patient is otherwise stable, and her hemoglobin is normal despite the melena, she

can be discharged.

2) Fibromyalgia Continue current medications

3) Hypertension Continue current medications.

4) Depression Continue current medications

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5) Constipation Continue current medications so patient can produce a stool sample

6) Interstitial cystitis continue current medications

7) Urge incontinence continue current medications

Citations

Mgraud F. The challenge of Helicobacter pylori resistance to antibiotics: the comeback of

bismuth-based quadruple therapy. Therap Adv Gastroenterol. 2012;5(2):103-9.

Cohen SH, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile

infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA)

and the infectious diseases society of America (IDSA). Infect Control Hosp Epidemiol.

2010;31(5):431-55.

Saha L. Irritable bowel syndrome: pathogenesis, diagnosis, treatment, and evidence-based

medicine. World J Gastroenterol. 2014;20(22):6759-73.