Date:
Patient:
MRN:
Clincian: (Gastroenterologist, Primary Care Physician)
Reason for Visit:
Follow-up for H. pylori infection
Review of initial diagnostic test results (stool antigen test, urea breath test, endoscopy with biopsy)
Discussion of treatment plan and potential side effects
Evaluation of treatment response and symptom improvement
History of Present Illness:
Briefly describe the patient’s current status:
Persistence or improvement of initial symptoms (upper abdominal pain, nausea, bloating, heartburn)
Any new or worsening symptoms since diagnosis
Compliance with dietary modifications (if recommended)
Past Medical History:
Underlying gastrointestinal conditions (peptic ulcer disease, gastritis)
Previous treatment for H. pylori infection (if applicable)
Social History:
Smoking history (increases risk of H. pylori complications)
Alcohol or NSAID use (can irritate stomach lining)
Family History:
Family history of peptic ulcer disease (may suggest increased risk)
Physical Exam:
Limited physical exam findings in uncomplicated H. pylori infection.
Consider mentioning abdominal palpation for tenderness if present.
Labs:
Confirmation of H. pylori infection:
Results of initial diagnostic test (stool antigen test, urea breath test, biopsy results if endoscopy performed).
Imaging:
Imaging studies are not typically needed for H. pylori diagnosis but may have been performed for evaluation of symptoms (abdominal X-ray, endoscopy).
Assessment:
Summarize the diagnosis of H. pylori infection based on the initial diagnostic test results.
Briefly discuss the potential complications of untreated H. pylori infection (peptic ulcer disease, gastritis).
Plan:
Outline the treatment plan:
Triple therapy: Combination of medications is standard for H. pylori eradication. This typically includes a proton pump inhibitor (PPI), two antibiotics (clarithromycin, amoxicillin, metronidazole), and sometimes bismuth subsalicylate (Pepto-Bismol).
Consider mentioning alternative regimens if clarithromycin resistance is suspected.
Discuss the expected duration of treatment (usually 1-2 weeks).
Reiterate the importance of completing the entire course of medication as prescribed, even if symptoms improve.
Prognosis:
Briefly discuss the prognosis. Treatment with eradication therapy is highly effective for curing H. pylori infection.
Emphasize the importance of retesting to confirm eradication after treatment completion (typically with a stool antigen test or urea breath test).
Education:
Document any education provided to the patient regarding:
The nature of H. pylori infection and its causes
The importance of adhering to the treatment plan and completing the full course of medication
Potential side effects of medications used in eradication therapy
Dietary modifications that may aid in healing and reduce stomach irritation (avoid spicy foods, alcohol, NSAIDs)
The importance of retesting to confirm eradication
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the diagnosis and treatment plan, and any concerns they may have about medication side effects, dietary changes, or the need for repeat testing.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with a gastroenterologist or primary care physician for diagnosis, treatment recommendations, and prognosis.