Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
Chief Complaint: Briefly describe the patient’s main reason for this visit. This could include:
Heartburn, acid reflux
Regurgitation (food coming back up)
Chest pain (atypical, may mimic angina)
Difficulty swallowing (dysphagia)
New or worsening symptoms
History of Present Illness:
Duration and severity of symptoms
Frequency of symptoms (daily, occasional)
Factors that worsen symptoms (large meals, certain foods, lying down)
Response to previous treatments (antacids, medications)
Any recent changes in symptoms or lifestyle
Past Medical History:
Gastroesophageal reflux disease (GERD) diagnosis
History of upper endoscopy or other relevant tests
Comorbid conditions (e.g., obesity, asthma)
Medications (prescription and over-the-counter) that may contribute to reflux (e.g., NSAIDs)
Smoking history
Family History:
History of hiatal hernia or GERD in first-degree relatives
Social History:
Diet (high in fat, spicy foods, caffeine, alcohol)
Smoking status
Stress levels
Physical Examination:
General appearance (signs of malnutrition if dysphagia present)
Vital signs (check for orthostatic hypotension if hiatal hernia is large)
Abdominal exam (organomegaly)
Laboratory Tests:
Complete blood count (CBC) – rule out other causes of symptoms (anemia)
Metabolic panel – check for electrolyte imbalances (if vomiting present)
Helicobacter pylori testing (may be considered if peptic ulcer disease suspected)
Imaging Studies:
Upper endoscopy (gold standard for diagnosis, may visualize hiatal hernia and other esophageal abnormalities)
Barium swallow (alternative to endoscopy, may show hiatal hernia size)
Chest X-ray (may be obtained incidentally and show signs of hiatal hernia)
Diagnosis:
Hiatal hernia (specify size, sliding or paraesophageal)
Gastroesophageal reflux disease (GERD) – may be a separate or associated diagnosis
Treatment Plan:
Lifestyle modifications (weight loss, dietary changes, avoiding triggers)
Medications:
Proton pump inhibitors (PPIs)
H2 receptor antagonists (less potent than PPIs)
Prokinetics (for esophageal emptying issues)
Surgery (considered for severe, uncontrolled GERD or complications)
Prognosis:
Discuss the outlook with treatment
Importance of lifestyle modifications for long-term management
Patient Education:
Explain hiatal hernia and GERD
Lifestyle changes to manage symptoms
Importance of medication adherence if prescribed
Warning signs for complications (worsening dysphagia, bleeding)
Importance of follow-up
Next Follow-up:
Schedule for the next appointment to monitor response to treatment and address any ongoing symptoms