Clinical note · #42
Consultation
Patient: Susan Miller
Age: 59
Place of Service: Office – Outpatient
Patient Status: Established Patient
Insurance: Medicare (Traditional / Part B)
Primary Provider: Dr. T. Anderson (Internal Medicine)
Reason for Visit: Follow-up evaluation of gastroesophageal reflux disease.
Chief Complaint: Heartburn controlled on medication.
History of Present Illness (HPI):
The patient is a 59-year-old female presenting for a routine follow-up visit for management of gastroesophageal reflux disease. She has been maintained on proton pump inhibitor therapy with good symptom control.
She reports occasional mild heartburn when dietary triggers are consumed but denies dysphagia, odynophagia, chest pain, nausea, vomiting, weight loss, or gastrointestinal bleeding. No emergency department visits or hospitalizations have occurred since her last visit.
Review of Systems (ROS):
- Gastrointestinal: Occasional heartburn
- Constitutional: Denies weight loss or fatigue
- Cardiovascular: Denies chest pain
- All other systems reviewed and negative
Past, Family, and Social History:
- PMH: GERD, hypertension
- PSH: Cholecystectomy
- FH: Noncontributory
- SH: Denies tobacco or alcohol use
Physical Examination:
- General: Well appearing, no acute distress
- Abdomen: Soft, non-tender, no guarding
- Cardiovascular: Regular rate and rhythm
Assessment:
- Gastroesophageal reflux disease – stable
Plan:
- Continue current proton pump inhibitor therapy
- Reinforce dietary and lifestyle modifications
- Follow up as needed or if symptoms worsen