Please feel free to either copy and paste the template below, or you can download it at the link below.
Let me know if you have any updates or corrections.
**Start of Template**
A/P
GERD diet reviewed at length, avoid triggers. Take medications daily as Rx. Elevate head at bedtime prn. Notify if sx worsen or change-may need to have further evaluation by GI with EGD if symptoms don’t improve
Diet was discussed as a possible trigger, patient advised to avoid food/drinks 2 hours before bedtime.
Currently no alarm symptoms such as weight loss, GI bleeding, or dysphagia
-Continue current PPI
-Can consider H2 blocker in addition to PPI if symptoms persist with PPI use
-Patient counseled on malabsoprtion of B12 and other vitamins with PPI use
-Patient counseled on long term use of PPI’s and how it can relate to osteoporosis
-Patient counseled on how use of PPI’s can potentially contribute to increased risk of C-Diff infections
-Patient would like to continue with PPI for now
– If no improvement then can consider referral to GI for endoscopy
Above recommendations for management of GERD with PPI and timeline for considering EGD are followed from the American College of Gastroenterology guidelines found at: https://journals.lww.com/ajg/Fulltext/2022/01000/ACG_Clinical_Guideline_for_the_Diagnosis_and.14.aspx
HPI
Patient reports a history of GERD for quite a while.
They take: {_}
Patient reports that their symptoms are currently well controlled, no issues with medications and no complaints from patient at this time relating to their GERD.
Has patient seen a GI specialist: {_}
**End of Template**