HISTORY:
for
, ,
,
Worsening factors:
Treatments tried: ,
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Throat:
Neck:
Heart: ,
Lungs: ,
Abdomen: , , ,
ASSESSMENT:
DDx:
PLAN:
- Upper GI endoscopy
- Dietary modifications (avoid spicy foods, caffeine, alcohol)
- Avoid eating 2-3 hours before bedtime
- Elevate head of bed
- Weight loss counseling
- Smoking cessation counseling
-
-
-
- Over-the-counter anti-acids
- Referral to gastroenterologist
- Follow-up in months
- Return if symptoms worsen or if new symptoms develop