Date:
Patient:
MRN:
Clincian: (Gastroenterologist, Primary Care Physician)
Reason for Visit:
Follow-up for GERD
Evaluation of symptom control and response to treatment
Discussion of lifestyle modifications and dietary management
History of Present Illness:
Briefly describe the patient’s current status:
Duration of GERD symptoms (heartburn, acid regurgitation, chest pain)
Frequency and severity of symptoms
Impact of symptoms on daily activities and sleep (sleep disturbances are common)
Response to previous treatment approaches (lifestyle changes, medications)
Past Medical History:
Underlying conditions that may contribute to GERD:
Hiatal hernia (weakening of the diaphragm allowing stomach contents to reflux)
Obesity
Pregnancy
Scleroderma (connective tissue disease)
History of esophageal disorders (esophagitis)
Social History:
Smoking (risk factor for GERD)
Alcohol use (risk factor for GERD)
Diet (high intake of fatty, spicy, or acidic foods can worsen symptoms)
Physical Exam:
Vital Signs: Usually normal unless there are complications (esophagitis).
Oropharynx exam: May reveal signs of chronic irritation from stomach acid (dental erosion).
Abdominal: Normal exam unless there are complications.
Labs:
Esophageal pH monitoring or upper endoscopy are usually not needed for diagnosis in typical cases. They may be considered if symptoms are severe, atypical, or don’t respond to treatment.
Complete Blood Count (CBC) – may be ordered to rule out other conditions if needed.
Consider mentioning other labs ordered as needed based on suspicion of other conditions.
Imaging:
Not routinely performed for diagnosis of uncomplicated GERD.
Upper GI series or barium swallow study – may be used if suspicion of hiatal hernia or esophageal stricture.
Esophagram – X-ray of the esophagus with contrast to evaluate for complications (esophagitis).
Assessment:
Summarize the diagnosis based on symptoms and response to treatment trials:
Confirmation of GERD diagnosis.
Severity of symptoms based on validated questionnaires (e.g., GERD-HRQ) if used.
Consideration of complications if suspected (esophagitis, strictures).
Plan:
Outline the treatment plan based on the assessment:
Lifestyle modifications:
Weight loss (if overweight or obese)
Dietary changes (avoid trigger foods, smaller and more frequent meals, avoid eating close to bedtime)
Smoking cessation
Elevating the head of the bed
Loose-fitting clothing
Medications:
Proton pump inhibitors (PPIs) – first-line therapy to reduce stomach acid production.
H2-receptor antagonists (less potent than PPIs but may be used as an alternative)
Prokinetic agents (to improve esophageal emptying) – may be used in specific cases.
Endoscopy/Surgery: Consideration for:
Severe GERD unresponsive to medical management
Suspicion of complications (esophageal strictures)
Barrett’s esophagus (precancerous condition)
Education:
Document any education provided to the patient regarding:
The nature of GERD and its causes
The importance of lifestyle modifications and dietary management in long-term control
The appropriate use of medications and potential side effects
Warning signs of complications that may require further evaluation (severe vomiting, difficulty swallowing)
Prognosis:
Briefly discuss the prognosis. GERD is a chronic condition, but symptoms can be effectively managed with lifestyle modifications and medications.
Early diagnosis and treatment can help prevent complications.
Emphasize the importance of ongoing communication with the healthcare provider to adjust the treatment plan as needed.
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the diagnosis and treatment plan, and any concerns they may have about medication adherence or lifestyle changes.