Gastritis

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents with a ‍-‍day history of ‍upper abdominal discomfort

Symptoms include:

‍epigastric discomfort

‍epigastric pain

‍nausea

‍vomiting, ‍ episodes ‍per day, ‍, ‍hematemesis

‍early satiety

‍loss of appetite

‍bloating

‍diarrhea, ‍ episodes ‍per day, ‍

‍constipation

‍melena, ‍withwithout strong foul smell

‍hematemesis



Worsening factors: ‍none

Alleviating factors: ‍none, ‍effectiveineffective



Contributing factors:

‍smoking

‍alcohol intake

‍stress

‍unhealthy diet

no history of: ‍gastritis, ‍H. pylori infection, ‍GERD, ‍peptic ulcer disease

no use of: ‍NSAID, ‍aspirin, ‍anti-acids





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍guarding, bowel sounds ‍normal, ‍, ‍CVA tenderness ‍

Anorectal: DRE ‍normal, prostate ‍normal, ‍blood, ‍mass, anus ‍

Extremities: ‍warm, ‍dry, cap refill ‍< 3> 3 sec, pulses ‍intact, ‍edema ‍bilaterally, ‍





ASSESSMENT:

‍Gastritis ‍likelysuspectedpossible

DDx: gastritis, peptic ulcer disease, GERD, pancreatitis, cholecystitis, hepatitis, gastroenteritis, food poisoning, medication side effects, alcohol consumption, stress-related mucosal disease, Helicobacter pylori infection, eosinophilic gastritis, radiation gastritis, Crohn's disease involving the stomach, gastric cancer, Zollinger-Ellison syndrome, portal hypertensive gastropathy





PLAN:

Investigations:

- Blood work: ‍CBC, ‍electrolytes, ‍creatinine, ‍LFTs, ‍lipase, ‍amylase, ‍H. pylori antibodies

- Stool test for H. pylori

- Breath test for H. pylori

- Upper GI endoscopy

- Abdominal ultrasound

Treatments:

- ‍PPIs

- ‍H2 blockers

- ‍Other antacids

- ‍H. pylori treatment

- Avoid NSAIDs

- Dietary modifications: ‍avoid spicy foods, ‍avoid alcohol, ‍avoid caffeine, ‍avoid acidic foods, ‍avoid fatty foods, ‍avoid carbonated beverages, ‍avoid dairy products

- Smoking cessation counseling

Further care:

- Referral to gastroenterologist

- Follow-up in ‍ ‍daysweeksmonths

- Return if symptoms worsen or if new symptoms develop such as vomiting, weight loss, or black stools