Patient: [Patient Name]
Date: [Date of Encounter]
I. Reason for Visit:
Follow-up visit for deprescribing proton pump inhibitor (PPI) therapy
Evaluation of any new symptoms after stopping PPI
II. History of Present Illness:
Current symptoms (heartburn, indigestion, dyspepsia) – assess severity and frequency
Duration of PPI therapy before deprescribing
Reason for initial PPI prescription (e.g., peptic ulcer disease, erosive esophagitis, GERD)
Response to PPI therapy (effective control of symptoms)
Any new symptoms since stopping PPI therapy (worsening of heartburn, new abdominal pain)
III. Past Medical History:
Underlying gastrointestinal (GI) conditions (peptic ulcer disease, GERD, hiatal hernia)
Hx of GI bleeding (consider if PPI use was for prophylaxis)
Other medical conditions and medications
IV. Social History:
Diet and lifestyle factors that may contribute to heartburn (alcohol, caffeine, spicy foods, smoking)
Stress levels (stress can worsen heartburn)
V. Physical Exam:
Vital signs (BP, HR, RR, Temp) – typically normal unless there are new acute GI issues
Abdominal exam (assess for tenderness, masses)
VI. Assessment:
Deprescribing of PPI therapy in progress.
Evaluation of response to deprescribing:
Improved or stable symptoms suggest successful deprescribing.
Worsening of heartburn may necessitate restarting PPI or considering alternative treatment options.
Consideration of underlying GI conditions and the need for continued acid suppression.
VII. Plan:
Continue monitoring for any return of heartburn symptoms.
Lifestyle modifications to reduce heartburn (diet changes, weight management, stress reduction).
Over-the-counter antacids (e.g., H2 blockers) can be used for occasional heartburn if needed.
Consider referral to a gastroenterologist if symptoms worsen significantly or there is concern for underlying GI pathology.
VIII. Prognosis:
Deprescribing PPIs can be successful for many patients, especially those who no longer require long-term acid suppression.
Discuss the importance of ongoing monitoring and lifestyle modifications to manage heartburn symptoms.
IX. Notes:
Document the patient’s understanding of the deprescribing process and potential side effects of stopping PPIs.
Provide education on lifestyle changes that can help manage heartburn.
Schedule follow-up appointments to monitor progress.
X. Resources:
Consider providing patient education materials on deprescribing PPIs and heartburn management from reputable sources (e.g., American College of Gastroenterology, National Institutes of Health).