i-Human Case Study: Week 7
Management Plan: Peptic Ulcer Disease (PUD)
➢ Problem Statement: This patient is a 50-Year-Old male with a PMH of dyslipidemia
and bilateral knee osteoarthritis presenting to clinic with complaint of experiencing
abdominal (ABD) pain and dyspepsia for several weeks to months. Reports "burning"
epigastric pain that is partially relieved by eating and antacids. Describes an episode of
coffee ground emesis and several episodes of melena, occurring several months ago.
Reports 30 year 1-PPD smoker, consumes alcohol daily (for 7-10 beers per week),
consumes take-out daily lunch at work, but balanced diet otherwise. No prescription
medications but takes daily: OTC 81 mg ASA for cardiovascular disease prevention,
200- 600 mg Ibuprofen for knee pain, and antacids (unknown amount.) No personal or
family history of bleeding D/O, mother with PMH of OA and osteoporosis. Physical
exam shows stable VS, FOBT negative and remaining physical exam unremarkable.
➢ Primary Diagnosis with coding:
K27 (Peptic Ulcer, Site
Unspecified)
A Peptic Ulcer is defined as an alteration to the mucosal and submucosal layers of the
gastrointestinal (GI) lining leading to vulnerability and damage from peptic acids resulting in a
sore (Mumukom , et. Al., 2024). The symptoms and relief of symptoms experienced by this
patient, such as burning epigastric pain that is partially relieved by eating and antacids, ABD
pain, and dyspepsia as well as a positive H. Pylori (Hp (+)) stool sample support the above
stated diagnosis. This patient also places himself at higher risks for PUD by consistently taking
NSAIDS and ASA, both, which commonly cause PUD. “Epigastric pain is the most common
symptom of both gastric and duodenal ulcers, characterized by a gnawing or burning sensation
and that occurs after meals—classically, shortly after meals with gastric ulcers and 2-3 hours
afterward with duodenal ulcers” (Anand, 2021).
Although this patient’s ethnicity is not disclosed, African Americans and Hispanics
have a higher incidence of H. pylori infection than whites (Brown, Cantrell, Tang, Epplein, &
Garman, 2022)
• CPT codes for office visit, history-taking, exam and procedures performed during
▪
this visit are as follows:
99205 – Office or other outpatient visit for the evaluation and management of a
new patient which requires a medically appropriate history and/or examination
▪
▪
and high medical decision making.
History: Comprehensive history
▪
Exam: Comprehensive exam
Medical decision-making: High complexity
, ▪ Typical face-to-face time: 60-74 minutes
▪ 85025 – CBC w/Diff
▪ 80053 – CMP
▪ B96.81 – Helicobacter pylori (Stool Test)
➢ Evidence-based guidelines were used by researching recent scholarly articles and past
evidenced-based practice to determine best practices to guide decision-making as a provider for
thorough investigation, recommendations, treatment and improve this patient’s clinical
outcomes while considering preferences and social determinants of health.
➢ Differential Diagnoses
▪
• K21 – Gastroesophageal Reflux Disease (GERD):
Typically, GERD symptoms include heartburn, regurgitation and dysphagia.
When the disease is in a prolonged or severe state, a patient may also
experience coughing and wheezing (Medscape, n.d.). On HPI the patient denies
dysphagia, which is a common symptom of GERD. Also, with GERD,
discomfort typically increases after eating, which is the opposite claim of this
patient. This diagnosis was ruled out by deductive reasoning.
•
▪
K85.9 – Pancreatitis:
Abdominal pain is considered the cardinal symptom of Pancreatitis, which my
patient has. Pancreatitis also manifests symptoms of sudden onset with
increasing severity and radiating, most often, to the back. Nausea, vomiting
(with unintentional anorexia) and diarrhea are common symptoms. A common
cause of Pancreatitis is alcohol misuse (Tang, 2021). My patient has a CAGE of
0/4 suggesting there is no concern for alcohol abuse. The above stated patient is
void of all symptoms with exception to ABD pain and characteristics are unlike
those of Pancreatitis. This diagnosis was ruled out by deductive reasoning.
•
▪
Neoplasm of the Stomach (D13.1 – Benign or C16.9 – Malignant):
Some risk factors for Gastric CA are smoking tobacco, alcohol consumption,
and infection H. pylori which the patient meets criteria. However, this patient
does not meet criteria for symptoms of loss of appetite, weight loss, abdominal
distention, a sense of fullness, even after a small meal (satiety), nor
unexplained
Management Plan: Peptic Ulcer Disease (PUD)
➢ Problem Statement: This patient is a 50-Year-Old male with a PMH of dyslipidemia
and bilateral knee osteoarthritis presenting to clinic with complaint of experiencing
abdominal (ABD) pain and dyspepsia for several weeks to months. Reports "burning"
epigastric pain that is partially relieved by eating and antacids. Describes an episode of
coffee ground emesis and several episodes of melena, occurring several months ago.
Reports 30 year 1-PPD smoker, consumes alcohol daily (for 7-10 beers per week),
consumes take-out daily lunch at work, but balanced diet otherwise. No prescription
medications but takes daily: OTC 81 mg ASA for cardiovascular disease prevention,
200- 600 mg Ibuprofen for knee pain, and antacids (unknown amount.) No personal or
family history of bleeding D/O, mother with PMH of OA and osteoporosis. Physical
exam shows stable VS, FOBT negative and remaining physical exam unremarkable.
➢ Primary Diagnosis with coding:
K27 (Peptic Ulcer, Site
Unspecified)
A Peptic Ulcer is defined as an alteration to the mucosal and submucosal layers of the
gastrointestinal (GI) lining leading to vulnerability and damage from peptic acids resulting in a
sore (Mumukom , et. Al., 2024). The symptoms and relief of symptoms experienced by this
patient, such as burning epigastric pain that is partially relieved by eating and antacids, ABD
pain, and dyspepsia as well as a positive H. Pylori (Hp (+)) stool sample support the above
stated diagnosis. This patient also places himself at higher risks for PUD by consistently taking
NSAIDS and ASA, both, which commonly cause PUD. “Epigastric pain is the most common
symptom of both gastric and duodenal ulcers, characterized by a gnawing or burning sensation
and that occurs after meals—classically, shortly after meals with gastric ulcers and 2-3 hours
afterward with duodenal ulcers” (Anand, 2021).
Although this patient’s ethnicity is not disclosed, African Americans and Hispanics
have a higher incidence of H. pylori infection than whites (Brown, Cantrell, Tang, Epplein, &
Garman, 2022)
• CPT codes for office visit, history-taking, exam and procedures performed during
▪
this visit are as follows:
99205 – Office or other outpatient visit for the evaluation and management of a
new patient which requires a medically appropriate history and/or examination
▪
▪
and high medical decision making.
History: Comprehensive history
▪
Exam: Comprehensive exam
Medical decision-making: High complexity
, ▪ Typical face-to-face time: 60-74 minutes
▪ 85025 – CBC w/Diff
▪ 80053 – CMP
▪ B96.81 – Helicobacter pylori (Stool Test)
➢ Evidence-based guidelines were used by researching recent scholarly articles and past
evidenced-based practice to determine best practices to guide decision-making as a provider for
thorough investigation, recommendations, treatment and improve this patient’s clinical
outcomes while considering preferences and social determinants of health.
➢ Differential Diagnoses
▪
• K21 – Gastroesophageal Reflux Disease (GERD):
Typically, GERD symptoms include heartburn, regurgitation and dysphagia.
When the disease is in a prolonged or severe state, a patient may also
experience coughing and wheezing (Medscape, n.d.). On HPI the patient denies
dysphagia, which is a common symptom of GERD. Also, with GERD,
discomfort typically increases after eating, which is the opposite claim of this
patient. This diagnosis was ruled out by deductive reasoning.
•
▪
K85.9 – Pancreatitis:
Abdominal pain is considered the cardinal symptom of Pancreatitis, which my
patient has. Pancreatitis also manifests symptoms of sudden onset with
increasing severity and radiating, most often, to the back. Nausea, vomiting
(with unintentional anorexia) and diarrhea are common symptoms. A common
cause of Pancreatitis is alcohol misuse (Tang, 2021). My patient has a CAGE of
0/4 suggesting there is no concern for alcohol abuse. The above stated patient is
void of all symptoms with exception to ABD pain and characteristics are unlike
those of Pancreatitis. This diagnosis was ruled out by deductive reasoning.
•
▪
Neoplasm of the Stomach (D13.1 – Benign or C16.9 – Malignant):
Some risk factors for Gastric CA are smoking tobacco, alcohol consumption,
and infection H. pylori which the patient meets criteria. However, this patient
does not meet criteria for symptoms of loss of appetite, weight loss, abdominal
distention, a sense of fullness, even after a small meal (satiety), nor
unexplained
