Episodic Visit: Gastrointestinal Focused Note

Episodic Visit: Gastrointestinal Focused Note

 Episodic note case study (GERD)

CC: Acid reflux 

HPI:

J is a 70-year-old black American woman in the office with complaints of ingestion for the past three days, she had acid reflux. She took over-the-counter Maalox with no relief. She said she was prescribed Protonix by her PCP. She stopped taking it because it did help with her symptoms.

Medical History:

GERD, CAD, HTN

Surgical History:

None

Review of Systems:

• General: Denies weight change, positive for stomach discomfort. Feels warm.

• Abdominal: Denies nausea and vomiting, denies loss of appetite

Objective

VSS T = 36.3°C, P = 80/min, RR = 18/min, and BP = 138/78 mm Hg.

Exam:

Diagnostics: 

Assessment:

.