What is the approach to taking a history and physical examination of a patient with peptic ulcer disease (PUD), considering their medical history, risk factors, and demographic information, such as age and sex?

History and Physical Examination of Peptic Ulcer Disease

Medical History - Key Elements to Elicit

Begin by systematically documenting symptom characteristics, medication exposures, and risk factors that directly influence diagnosis and management decisions.

Symptom Characterization

• Epigastric pain pattern: Ask specifically about pain relieved by food intake or antacids, pain that awakens the patient at night, or pain occurring between meals—these are classic patterns for peptic ulcer disease 1, 2
• Timing and duration: Document when symptoms began and their progression, as older patients (≥80 years) present with epigastric pain in 74% of cases 3
• Associated symptoms: Systematically inquire about nausea, vomiting, loss of appetite, and weight loss 1, 4
• Alarm symptoms requiring immediate endoscopy: Specifically ask about hematemesis, melena, severe persistent vomiting, unintentional weight loss >10%, dysphagia, or odynophagia 2

Medication History - Critical for Risk Stratification

• NSAID and aspirin use: Document all nonsteroidal anti-inflammatory drugs including over-the-counter medications, as NSAIDs are etiologic in approximately 36% of peptic ulcer disease cases 2
• Aspirin for cardiovascular prophylaxis: This is particularly important in elderly patients, who have higher complication rates (69% in patients ≥80 years) when using aspirin or NSAIDs 3
• Anticoagulant or antiplatelet agents: These increase bleeding risk if ulceration occurs 5
• Recent antibiotic use: May affect Helicobacter pylori testing accuracy 4
• Proton pump inhibitor use: Document current or recent use, as this affects diagnostic testing 4

Risk Factor Assessment

• Helicobacter pylori exposure: Ask about previous testing or treatment, as this affects approximately 42% of peptic ulcer disease patients 2
• Smoking history: Document current and past tobacco use 1
• Alcohol consumption: Quantify frequency and amount 1
• Family history: Specifically ask about peptic ulcer disease, gastric cancer, or inflammatory bowel disease in first-degree relatives 6
• Previous ulcer history: Document prior episodes, complications, and treatments 1

Age-Specific Considerations

• Elderly patients (≥80 years): These patients more commonly have H. pylori-negative ulcers (65%), nearly equal distribution between gastric and duodenal ulcers, and significantly higher complication rates 3
• Younger patients (<60 years) without alarm symptoms: Can be managed with test-and-treat strategy rather than immediate endoscopy 1, 4

Physical Examination - Systematic Approach

Vital Signs Assessment

• Tachycardia and fever: These suggest complications such as perforation with peritonitis 6, 7
• Blood pressure and heart rate: Document baseline values; tachycardia >94 bpm predicts non-operative management failure in perforated ulcers 6
• Temperature: Fever indicates potential perforation or penetration 7
• Weight: Document for comparison with previous visits to assess weight loss 1

Abdominal Examination - Sequential Approach

• Inspection: Look for distension or visible peristalsis, which may indicate gastric outlet obstruction 6
• Auscultation: Perform before palpation; absent bowel sounds suggest perforation with peritonitis 7
• Palpation for tenderness: Epigastric tenderness is common in uncomplicated peptic ulcer disease 1, 2
• Guarding and rebound tenderness: These indicate peritoneal irritation from perforation 7
• Board-like rigidity: This is a hallmark finding of perforated peptic ulcer requiring immediate surgical consultation 7

Signs of Complications Requiring Urgent Intervention

• Diffuse peritonitis with hemodynamic instability: Immediate surgical consultation takes precedence over complete diagnostic workup 8, 7
• Signs of septic shock: Altered mental status, tachypnea, reduced pulse pressure, decreased urine output require rapid resuscitation with target MAP ≥65 mmHg and urine output ≥0.5 ml/kg/h 6
• Pallor and tachycardia without peritonitis: Suggests bleeding ulcer, the most common complication (73% of complicated cases) 5, 2

Rectal Examination

• Digital rectal examination: Perform to detect melena or gross blood, indicating upper gastrointestinal bleeding 6, 1

Clinical Decision Points Based on History and Physical

Immediate Endoscopy Indications

• Age ≥60 years with new-onset dyspepsia 4, 2
• Any alarm symptoms present (bleeding, weight loss, dysphagia, persistent vomiting) 1, 4, 2
• Signs of complications (peritonitis, obstruction, bleeding) 5, 2

Test-and-Treat Strategy Appropriate

• Age <60 years 1, 4
• No alarm symptoms 1, 4
• Typical peptic ulcer symptoms (epigastric pain relieved by food/antacids) 1

Common Pitfalls to Avoid

• Underestimating elderly patients: Patients ≥80 years have 69% complication rates and often present atypically; maintain high suspicion even with mild symptoms 3
• Missing NSAID/aspirin use: Always ask specifically about over-the-counter medications and low-dose aspirin for cardiovascular prophylaxis 2, 3
• Delaying surgical consultation in perforation: When board-like rigidity or diffuse peritonitis with hemodynamic instability is present, immediate surgical evaluation supersedes complete diagnostic workup 8, 7
• Assuming H. pylori is always present: In elderly patients, 65% of ulcers are H. pylori-negative, with NSAID use being the predominant cause 3