Patient Profile
Patient: Mr. Arvind Mehta, 45-year-old male, Software Engineer
Chief Complaint: Epigastric pain and bloating for 2 months, worse on an empty stomach
History & Examination
- Medical history: Occasional NSAID use for back pain
- Lifestyle: High stress, irregular meals, frequent coffee intake
- Physical exam: Mild epigastric tenderness
Investigations
- Urea breath test: Positive for H. pylori
- Upper GI endoscopy: Gastric ulcer in the antrum; no active bleeding
- CBC: Mild anemia (Hb 11.2 g/dL)
- Stool occult blood: Negative
Diagnosis
Peptic Ulcer Disease secondary to Helicobacter pylori infection. NSAID exposure considered a contributing factor.
Management Plan
Pharmacological (14 days)
- Omeprazole 20 mg twice daily (PPI)
- Amoxicillin 1 g twice daily
- Clarithromycin 500 mg twice daily
- Iron supplementation for anemia
- Avoid: NSAIDs and aspirin
Lifestyle Modifications
- Dietary guidance: Limit spicy, acidic, and caffeinated foods
- Structured meals; reduce stress (mindfulness/yoga)
- Smoking and alcohol cessation if applicable
Follow‑Up Plan
- 4 weeks: Assess symptom resolution
- 6 weeks: Repeat urea breath test to confirm eradication
- 3 months: Consider repeat endoscopy if symptoms persist
Outcome Goals
- Ulcer healing and pain resolution
- Confirmed eradication of H. pylori
- Prevention of recurrence
Long‑Term Considerations
- Education on NSAID risks and alternatives
- PPI prophylaxis if NSAIDs are required in the future
- Monitor for complications: bleeding, perforation, gastric cancer risk
References
- Chey WD, Leontiadis GI, Howden CW, Moss SF. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. Am J Gastroenterol. 2017;112(2):212–239.
- Primary Care Case Studies 101. Sampath Wijesinghe. Springer Publishing.