GERD

HISTORY:

‍Heartburn for ‍ ‍hoursdays

‍acid reflux

‍pyrosis

‍regurgitation

‍chest pain, ‍retrosternal, ‍on exertionat restwith deep breath

‍cough, ‍non-productiveproductive

‍sputum, ‍clearcolored

‍belching

‍epigastric pain

‍dysphagia

‍odynophagia

‍hoarseness

‍sour taste in mouth

‍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:

- Blood work: ‍CBC, ‍electrolytes, ‍creatinine, ‍LFTs, ‍lipase, ‍amylase

- Upper GI endoscopy

- Barium swallow

- 24-hour pH monitoring

- ‍PPIs

- ‍H2 blockers

- ‍Antacids

- Dietary modifications: ‍avoid spicy foods, ‍avoid alcohol, ‍avoid caffeine, ‍avoid acidic foods, ‍avoid fatty foods, ‍avoid carbonated beverages, ‍avoid large meals, ‍avoid eating within 3 hours of bedtime

- Stop NSAIDs and other medications that may contribute to GERD

- Weight loss counseling

- Smoking cessation counseling

- Elevate head of bed

- Referral to gastroenterologist

- Follow-up in ‍ ‍daysweeksmonths

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

- Go to ER if severe chest pain, difficulty breathing, or vomiting blood occurs