消化性溃疡英文病历.doc

消化性溃疡英文病历
A 37-year-old executive returns to your office for follow up of recurrent upper abdominal pain. He initially presented 6 weeks ago, complaining of an increase in frequency and severity of burning epigastric pain, which he's had occasionally for more than 2 years. He now has the pain three or four times a week, usually on an empty stomach, and it often awakens him at night. The pain is usually relieved within minutes by food or over-the-counter antacids, but recurs within 2-3 hours. He admitted that stress at work had recently increased and that because of long working hours, he was drinking more caffeine and eating a lot of "take-out" foods. His past medicai history and review of systems were otherwise unremarkable, and other than the antacids, he takes no medications. His physical exam was normal, including stool guaiac that was negative for occult blood. You advised a change in diet and started him on an H:-bloeker. His symptoms pletely with the diet changes and daily use of the medication. Lab tests done at his first visit shows no anemia, but his serum Helicobacter pylori antibody test was positive.
+ What is your diagnosis? + What is your nest step?
ANSWERS: Peptic Ulcer Disease
Summary: A 37-year-oid man plaining of chronic and recurrent upper abdominal pain with characteristics suggestive of duodenal ulcer: the pain is burning in quality, occurs when the stomach is empty, and is relieved within minutes by food or antacids. He does not have evidence of gastrointestinal bleeding or anemia. He does not take nonsteroida! antiinflammatory drugs, which might cause ulcer formation, but he does have serological evidence of H. pylori infection.
Most likely diagnosis: Peptic ulcer disease.
Next step; Antibiotic therapy for K pylori infection.
Analysis
Objectives
Know how to mon causes of abdominal pain by his
torical clues.
Recognize clinical features of duodenal ulcer, gastric ulcer, and fea
tures that increase concern for gastric cancer.
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