Pertinent ROS: No diarrhea, no constipation, no bloody stools, no black tarry stools, no severe abdominal pain, no fevers, no chills, no night sweats, no overseas travel, no sick contacts at home, no known TB exposures, no trauma to the chest or throat, did not inhale any substances, denies any abnormal occupational exposures, and does not smoke or drink alcohol.
27 yo stable, well appearing M w/previously benign pmh who presented last week w/hx of hematemesis, hemoptysis, weakness/fatigue, and shortness of breath for 2 weeks that is now subjectively improving, per patient. Pathology from EGD shows evidence of H. pylori and chronic gastritis. Likely the source of his bleeding. May also have had a Mallory Weiss tear given his history of vomiting and retching. However, w/ history of hematemesis and hemoptysis in conjunction w/tachycardia, there remains a concern for active bleeding. Previous CBC last week WNL, but will repeat to r/o bleeding and begin treating H. pylori infection w/quadruple therapy.
- Quad therapy: Tetracylcine, metronidazole, omeprazole, bismuth subsalicylate for 14 days.
- Counsel patient to not drink any alcohol while taking metronidazole as this can cause an adverse reaction. Patient acknowledges and agrees.
- CBC to r/o active bleeding. Will call patient if abnormal.