Dear Bob,

This is a follow-up letter to our brief discussion as a background, she has had 20 years of
“nervous stomach”, describing abdominal discomfort with certain fluids and stress. She will get
relieved in Donnatal, Di-gel and Maywatch. Additionally, she had been taking eight exergen a day for
approximately 20 years.

More recently for her shoulder problem, she was treated with Prednisone, Naphazoline, Flexeril,
exergen with codeine, Percodan, having been rough all prednisone and naphazoline for
approximately four weeks. However, despite being off those medications, she still describes some
“indigestion” describe at the mid of the gastric with discomfort associated with mild nausea. This
discomfort is worse with food and with tight clothes. She described loss-of-appetite and basically
being afraid to eat anything. She has no visible bloating, vomiting, ascites gurgitation, maternal
symptoms, or dysphagia. She doesn’t describe some improvement in the symptoms with
certocrackers, cream demen and liquid maylox as well as belching. She continues to take eight
exergen per day.

Her physical examination was remarkable for findings lately like pleural effusion and her stool was
hemoccult positive.

In due of her many years of dyspeptic symptoms, her recent multiple drug ingestion, as well as the
continued aspirin intake, one has to presume that her mid at the gastric discomfort and nausea are
due to these medications and the continued use of aspirin. In view of this likelihood, it would be
most reasonable to treat her presumptively with Tagamet as well as taking her off regular aspirin
and placing her on Ecotrin (The enteric coded aspirin) which seems to have less gastro-duodenal
effects. Two days and we started her on Ecotrin, Tagamet, and should she have no improvement of
her symptoms of the next several weeks, then endoscopy is recommended to evaluate her pain

Thank you bob for rescuing this serious patient and should she have no improvement I will keep you
informed on the results.