SUBJECTIVE: The patient returns for followup. She relates she has been doing well, except that since February, she has had epigastric pain. She took omeprazole first once daily and then b.i.d. and felt somewhat better. She took it for about a month and then tapered to off. Last week, she had an episode of hematemesis with bright red blood. She reports she was not retching prior to the hematemesis. She had a dark stool, but no frank melena after that.
OBJECTIVE: Vital Signs: Blood pressure 102/64, weight 140. Chest: Clear. Heart: Regular rate and rhythm. Abdomen: Positive bowel sounds with mild epigastric tenderness. No rebound or guarding. No peritoneal signs. Rectal Exam: No masses and brown Hemoccult-negative stool.
ASSESSMENT: Epigastric pain with an episode of hematemesis.
PLAN: Recommend an upper endoscopy and order was put through for the same. The patient has no signs of active bleeding and is currently Hemoccult negative from below. Restart omeprazole b.i.d. Check liver tests, CBC, amylase, lipase, and a pregnancy test.
SUBJECTIVE: The patient is a pleasant (XX)-year-old female who presents today in gastroenterology clinic for followup of nausea, vomiting, and reflux. The patient has been taking omeprazole twice per day and ranitidine at bedtime. She reports her reflux has dramatically improved. She had isolated episode of vomiting. Otherwise, she feels much better. She underwent an upper endoscopy, which revealed a large 4 cm hiatal hernia, otherwise normal.
OBJECTIVE: Weight today is stable at 170 pounds. Remainder of physical examination is deferred.
ASSESSMENT AND PLAN: The patient is a (XX)-year-old female with nausea and vomiting. Reflux is currently much improved on omeprazole, twice per day dose, and ranitidine at bedtime. The patient at this point will follow up with us in one year’s time. She is encouraged that if symptoms worsen in the interim, she should contact us. We did also discuss seeing a surgeon for repairing the hiatal hernia. However, at this point, the patient’s symptoms are well controlled on medication and that does not appear necessary.
SUBJECTIVE: The patient is a very pleasant (XX)-year-old gentleman with a history of ulcerative colitis with a flare requiring hospitalization two years ago. Most recent colonoscopy was normal. He had been on Asacol and we attempted to switch him to Lialda, but he had a violent reaction with worsening abdominal pain, nausea, vomiting, and headaches. Now, he takes only Cortifoam nightly, and this helps with his symptoms. He continues to have epigastric/periumbilical abdominal pain for which he takes omeprazole 20 mg daily, and this may or may not help. CT scan of the abdomen and pelvis a couple of months back was otherwise normal. We tried Donnatal, but he had side effects from this. He was doing quite well for a while, but in the recent past has had some diarrhea with blood. Yesterday and today, he has been feeling better. He had increased the fiber in his diet more recently and is now planning to back off.
OBJECTIVE: Weight 176 pounds. Pain score 2/10 in the abdomen. In general, this is a nontoxic-appearing (XX)-year-old gentleman, in no apparent distress. Abdomen is benign.
ASSESSMENT AND PLAN: This is a very pleasant (XX)-year-old gentleman with left-sided ulcerative colitis, currently doing well on Cortifoam nightly. He had a recent small flare, but this seems to be getting better. We told him to avoid excessive fiber foods, but concentrate on soft fruits and well-cooked vegetables. He has been exercising recently and is taking good care of himself. He wonders whether he can stop omeprazole. We told him he can try, but if symptoms return, immediately resume it. In terms of his epigastric pain, we feel this is nonulcer dyspepsia. At his last visit, we spoke about starting desipramine 10 mg nightly, but he has not tried this as of yet. He can stop the omeprazole and see if his symptoms return. Otherwise, we should monitor for further flares, and he may require immunomodulators. However, we do feel he has significant irritable bowel syndrome overlay, and before embarking on stronger medication, he would need colonoscopy for restaging if he were having persistent symptoms.
