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Gastroesophageal reflux disease (GERD) refers to symptoms or damage caused by stomach contents abnormal moving back up into the esophagus. The main symptoms are heartburn, excessive saliva, belching, and regurgitation. Treatment aims to reduce or eliminate symptoms, decrease how often and long reflux occurs, promote healing of injured tissue, and prevent complications from developing.

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2K views1 page

TB Soap Note

Gastroesophageal reflux disease (GERD) refers to symptoms or damage caused by stomach contents abnormal moving back up into the esophagus. The main symptoms are heartburn, excessive saliva, belching, and regurgitation. Treatment aims to reduce or eliminate symptoms, decrease how often and long reflux occurs, promote healing of injured tissue, and prevent complications from developing.

Uploaded by

Numerator
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Gastroesophageal reflux disease (GERD)

GERD refers to symptoms or mucosal damage resulting from the abnormal retrograde movement
of gastric contents from the stomach into the esophagus. The hallmark symptoms are heartburn,
hypersalivation, belching, and regurgitation. The goals of treatment are to reduce or eliminate
symptoms, decrease the frequency and duration or gastroesophageal reflux, promote healing of
the injured mucosa, and prevent the development of complications.

Pt is currently on:
o Lansoprazole 30mg capsule 1 capsule PO before breakfast
Recommend
o Continuing Lansoprazole 30mg PO before breakfast
o Elevating head of bed to increase esophageal clearance
o Take medications which irritate the esophageal mucosa with plenty of liquid
o Lifestyle modifications
Avoid foods that may decrease lower esophageal sphincter pressure (fats,
chocolate, alcohol, etc)
Avoid tight fitting clothing
Avoid eating at bedtime
Monitor
o Re-evaluate patients symptoms after 4 weeks
o Any atypical symptoms including cough and chest pain
o Adverse drug events (i.e. nausea, diarrhea, abdominal pain, etc)

The goals of therapy are to minimize pain and provide reasonable comfort at the lowest
effective analgesic dose.

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