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:
- Blood work: , , , , ,
- Upper GI endoscopy
- Barium swallow
- 24-hour pH monitoring
-
-
-
- Dietary modifications: , , , , , , ,
- Stop NSAIDs and other medications that may contribute to GERD
- Weight loss counseling
- Smoking cessation counseling
- Elevate head of bed
- Referral to gastroenterologist
- Follow-up in
- Return if symptoms worsen or if new symptoms develop such as difficulty swallowing, weight loss, or black stools
- Go to ER if severe chest pain, difficulty breathing, or vomiting blood occurs