Subjective
Date of visit
Reason for visit (initial presentation, follow-up)
History of present illness:
Abdominal pain (location, character, severity, radiation)
Burning sensation in the stomach (heartburn)
Nausea and vomiting
Early satiety (feeling full after eating a small amount)
Weight loss (unintentional)
Changes in bowel habits (constipation, diarrhea)
Risk factors for peptic ulcer disease (NSAIDs use, smoking, H. pylori infection)
Past medical history (relevant conditions, previous surgeries)
Medications (current medications, including over-the-counter medications like NSAIDs)
Allergies
Objective
Vital signs (temperature, heart rate, blood pressure)
Physical exam:
Abdominal examination (tenderness, guarding, mass)
Assessment
Peptic ulcer disease (suspected):
Location of ulcer (gastric ulcer vs. duodenal ulcer) based on pain location and other clinical features
Consider severity based on symptoms and complications (bleeding, perforation)
Differential diagnoses (gastritis, gastroesophageal reflux disease – GERD)
Plan
Diagnostic testing (may be ordered depending on presentation):
Upper endoscopy with possible biopsy to visualize the ulcer and potentially diagnose H. pylori infection
Stool test or breath test for H. pylori infection
Upper gastrointestinal (GI) series with X-ray (less common nowadays)
Treatment:
Aims to eradicate H. pylori (if present) and promote ulcer healing
Medication regimen typically includes:
Proton pump inhibitors (PPIs) to reduce stomach acid production
Antibiotics (clarithromycin, amoxicillin) to eradicate H. pylori (if present)
Cytoprotective agents (sucralfate) may be added in some cases
Lifestyle modifications:
Diet modifications (avoiding spicy foods, irritants, alcohol)
Smoking cessation (if applicable)
Education
Explain the diagnosis and treatment plan
Importance of medication adherence and follow-up appointments
Follow-up
Schedule for next appointment:
Monitor response to treatment (symptom improvement)
Endoscopy follow-up (if indicated) to confirm ulcer healing
H. pylori eradication testing (if applicable)
Note: This is a template and may need to be modified based on the individual patient’s presentation, severity of symptoms, and presence of H. pylori infection.
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of peptic ulcer disease.