Case
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Patient Progress Notes
Date: 4/1/25
Seen by: C/S/B — General Medicine PG (Postgraduate resident)
Assessment (Δˢˢ):
- Erosive Gastritis (peptic — crossed out/amended)
- RUT +ve — Rapid Urease Test positive (indicating H. pylori infection)
Treatment Plan (Rx):
| # | Order | Details |
|---|---|---|
| 1 | IVF | 200 DNS + 205% D (DNS = Dextrose Normal Saline; D5 = 5% Dextrose) @ 75 ml/hr |
| 2 | Inj. Pan 40 mg | Pantoprazole 40 mg IV BD (twice daily) — proton pump inhibitor |
| 3 | Inj. Zofer 4 mg | Ondansetron 4 mg IV TID (three times daily) — antiemetic |
| 4 | H.P. Kit | Helicobacter pylori eradication kit — as per strip, PO BD (oral, twice daily) |
| 5 | Syp. Sucral-O 10 ml | Sucralfate oral suspension 10 ml PO TID — mucosal protectant |
Follow-up Note (4/1/25 — 5 PM):
- C/O/S — Gen Med: Need PG on duty
- Δˢˢ: Erosive Gastritis + RUT +ve
- No fresh complaints
- Vitals stable
- Signed: Dr. C.S.T.
Clinical Summary
This patient has erosive gastritis with a positive RUT, confirming H. pylori infection. The management follows standard protocol:
- IV Pantoprazole — acid suppression to allow mucosal healing
- H.P. Kit — standard triple/quadruple therapy for H. pylori eradication (typically includes clarithromycin, amoxicillin, and a PPI)
- Ondansetron — symptom control for nausea/vomiting
- Sucralfate — mucosal cytoprotection
- IV fluids — hydration support
The evening review confirmed no deterioration, stable vitals, and no new complaints — indicating a satisfactory initial response to treatment.
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