In a 20‑year‑old male with resolved acute epigastric burning pain and projectile vomiting after omeprazole and antacid/simethicone therapy, normal physical exam and no red‑flag features, what further evaluation, laboratory tests, or medications are needed before clearing him for work?

Management of Resolved Acute Dyspepsia Before Return to Work

This 20-year-old male with completely resolved symptoms after empiric PPI and antacid therapy can be cleared for work immediately without additional testing or prescriptions, provided you document the absence of alarm features and counsel him on recurrence.

Immediate Assessment

No further laboratory testing or imaging is required because:

• He is under 25 years old, which is below the threshold for mandatory complete blood count 1
• His symptoms have completely resolved after 1 day of therapy 1
• He has no alarm features: no weight loss, no anemia symptoms, no dysphagia, no hematemesis, and no persistent vomiting 1, 2
• His physical examination is entirely normal with normal vital signs 1
• The projectile vomiting has ceased and was brief (4 episodes over 2 days), not persistent 2, 3

Cardiac Exclusion Not Required

An electrocardiogram is not indicated in this case because:

• He is 20 years old with no cardiac risk factors 2, 3
• The pain was clearly epigastric and "acidic" in character, not exertional 2, 3
• There were no associated cardiac symptoms (dyspnea, diaphoresis, radiation to jaw/arm) 2, 3
• Symptoms resolved completely with acid suppression 2, 3

H. pylori Testing Decision

H. pylori testing is not urgently needed before return to work because:

• His symptoms resolved rapidly with empiric therapy 1
• He can return to work now and undergo outpatient ^13C-urea breath test or stool antigen testing (not serology) if symptoms recur 1, 3
• Test-and-treat strategy is appropriate for young patients without alarm features, but does not need to delay work clearance when asymptomatic 1

Endoscopy Not Indicated

Upper endoscopy is not required because:

• Age < 25 years without alarm features does not meet criteria for urgent or non-urgent endoscopy 1
• Treatment-resistant dyspepsia requiring endoscopy is defined as symptoms persisting despite 4–8 weeks of full-dose PPI therapy; he responded in 1 day 1, 3
• The brief, self-limited course makes functional dyspepsia or serious organic pathology unlikely 1, 2

Prescription Recommendations for Work Clearance

Continue omeprazole 20 mg once daily before breakfast for a total of 4 weeks, then stop:

• This provides a complete therapeutic course for presumed acute gastritis or GERD 3, 4, 5
• Omeprazole 20 mg daily achieves 80–90% healing of duodenal ulcers and provides sustained symptom relief 4, 5
• The antacid/simethicone (Kremil S) can be used as needed for breakthrough symptoms but is not required for daily maintenance 6

Do not prescribe additional medications such as:

• Prokinetics are not indicated for resolved symptoms 1
• Antiemetics are unnecessary when vomiting has ceased 2
• Antispasmodics have no role in resolved dyspepsia 1

Fit-to-Work Documentation

Clear him for full work duties immediately with the following documentation:

• Diagnosis: Acute dyspepsia, resolved (likely acute gastritis or GERD) 1, 2
• Treatment: Omeprazole 20 mg daily × 4 weeks total 3, 4
• No work restrictions required 1
• Symptoms completely resolved, normal physical examination, no alarm features present 1, 2

Patient Education and Red-Flag Counseling

Counsel the patient to return immediately if any of the following develop:

• Persistent vomiting (> 24 hours) or inability to tolerate oral intake 1, 2
• Hematemesis, coffee-ground emesis, or black tarry stools 2, 3, 7
• Severe, unrelenting epigastric pain or pain with fever/rigidity 2, 3
• Unintentional weight loss > 5% body weight 1, 7
• New dysphagia or sensation of food sticking 1, 7

Provide lifestyle modification advice:

• Avoid lying down within 2–3 hours after meals 3
• Reduce coffee and citrus intake, which commonly trigger symptoms 3
• Avoid NSAIDs (ibuprofen, aspirin), which worsen gastritis and ulcer risk 2, 3
• Eat smaller, more frequent meals rather than large portions 3

Follow-Up Plan

Schedule outpatient follow-up in 4 weeks (after completing PPI course) to:

• Assess for symptom recurrence after stopping omeprazole 1, 3
• Perform H. pylori stool antigen or breath test if symptoms have returned 1, 3
• Consider endoscopy only if symptoms persist despite full 4-week PPI course or if alarm features develop 1, 3

Common Pitfall to Avoid

Do not delay work clearance to pursue H. pylori testing or endoscopy in a young, asymptomatic patient without alarm features—this represents overinvestigation and unnecessarily prolongs work absence 1. The British Society of Gastroenterology explicitly states that endoscopy is not indicated for treatment-responsive dyspepsia in patients under 25 years without alarm features 1. His rapid, complete response to empiric therapy confirms a benign, self-limited process 2, 3.