Gastroesophageal Reflux Disease follow-up

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Returns for a ‍GERD follow-up

Last visit was ‍ ‍months ago

Progress since last visit: ‍unchangedimprovedworsenedvariable in intensityresolved



Updates on symptoms:

‍heartburn

‍regurgitation

‍chest pain, ‍retrosternal, ‍aching, ‍on exertionat restwith deep breath, ‍mild

‍cough, ‍non-productiveproductive of ‍clearcolored phlegm

‍belching

‍epigastric pain

‍dysphagia

‍odynophagia

‍hoarseness

‍sour taste in mouth

‍nausea



Medication tried: ‍PPI, ‍H2 blocker, ‍antacids, ‍effectiveineffective, ‍adverse effect, ‍good adherence

Diet triggers identified: ‍fatty foodsacidic foodsspicy foodsAlcoholcaffeine

Dietary changes: ‍noneless spicy foods, ‍effectiveineffective

Lifestyle modifications: ‍noneweight loss, ‍effectiveineffective





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

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

Throat: ‍normal, ‍erythema, ‍exudate, ‍

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍

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





ASSESSMENT:

‍GERD ‍likelysuspectedpossible, ‍well-controlled

DDx: GERD, non-erosive reflux disease, erosive esophagitis, Barrett's esophagus, hiatal hernia, gastroparesis, gastritis, peptic ulcer disease, Zollinger-Ellison syndrome, esophageal motility disorders, esophageal stricture, esophageal cancer, laryngopharyngeal reflux, acute coronary syndrome, biliary tract disease, eosinophilic esophagitis, pill esophagitis, functional heartburn





PLAN:

Investigations:

- Upper GI endoscopy

- Barium swallow

- 24-hour pH monitoring

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

Treatments:

- ‍PPIs

- ‍H2 blockers

- ‍Other 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

Further care:

- 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