Acid Reflux

HISTORY:

‍Acid reflux for ‍ ‍hoursdays

‍heartburn

‍regurgitation

‍chest pain, ‍retrosternal, ‍on exertionat restwith deep breath

‍cough, ‍non-productiveproductive

‍belching

‍sore throat

‍hoarseness

‍sour taste in mouth

‍dysphagia

‍bloating

‍nausea

Worsening factors: ‍none

Treatments tried: ‍none, ‍effectiveineffective



EXAM:

General appearance: ‍well-appearing

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

Throat: ‍normalrednessexudate

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

Abdomen: ‍softsemi-softtense, ‍non-tender ‍, ‍non-distended, ‍



ASSESSMENT:

‍GERD ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Upper GI endoscopy

- Dietary modifications (avoid spicy foods, caffeine, alcohol)

- Avoid eating 2-3 hours before bedtime

- Elevate head of bed

- Weight loss counseling

- Smoking cessation counseling

- ‍PPIs

- ‍Ranitidine

- ‍Sucralfate

- Over-the-counter anti-acids

- Referral to gastroenterologist

- Follow-up in ‍ months

- Return if symptoms worsen or if new symptoms develop