CHIEF COMPLAINT: Acid reflux.
HISTORY OF PRESENT ILLNESS: The patient was seen today acutely for acid reflux. She is a very pleasant (XX)-year-old female who presents today for the above concerns. She has had this ongoing now for 6 years. The patient was told that she needed an EGD years ago but was too nervous to get that done, so she put that off.
She states this has worsened over the last 4 weeks. She states any foods randomly will cause discomfort in the epigastrium with radiation up to the chest. She states it is associated also with nausea and shortness of breath about 30 minutes to an hour after eating.
She does not have any late night eating after 8 p.m., and she use over-the-counter Prozac, Zantac, Pepcid and Tums. Zantac work the best but nothing was long term. She also uses Motrin on a regular basis secondary to an ankle surgery.
REVIEW OF SYSTEMS: Other review of systems is negative for 11 systems reviewed, except as stated in the HPI. No melena, hematochezia or hematemesis.
PAST MEDICAL HISTORY/MEDICATIONS/ALLERGIES/SOCIAL HISTORY/FAMILY HISTORY: All reviewed in the chart. Of note, she is on Motrin fairly regularly because of discomfort.
PHYSICAL EXAMINATION:
VITAL SIGNS: She is afebrile, pulse 68, blood pressure 102/52, and weight 120 pounds.
GENERAL: She is in no apparent distress. She is a pleasant, awake, alert and oriented x3 female.
HEENT: Normocephalic and atraumatic. Extraocular muscles are intact. Oropharynx is clear. Moist mucous membranes. Dentition is intact.
NECK: Supple without anterior cervical or supraclavicular adenopathy. No JVD, bruits or thyromegaly.
HEART: Regular rate and rhythm without murmurs, rubs, gallops or thrills. Her PMI is normal.
LUNGS: Clear to auscultation. No wheeze, rales or rhonchi.
ABDOMEN: Soft and distended. No rebound, guarding or rigidity. No pulsatile masses or hepatosplenomegaly.
EXTREMITIES: No clubbing, cyanosis or edema.
SKIN: Warm and dry. No rash or lesions.
IMPRESSION:
1. Gastroesophageal reflux disease.
2. Epigastric pain, likely secondary to nonsteroidal anti-inflammatory drug-induced gastritis.
PLAN: The patient will be given Nexium 40 mg daily. We will refer her for upper endoscopy, and we will check LFTs and lipase level and H. pylori antibody. She has understanding of this and will call with the above lab results.
