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Gastro Esophageal Reflux Disease 

Directions

Please include:

1. Demographic information of the patient
2. Chief complain.
3. History of present illness. Fallowing the mnemonic old chart: Onset/Location/Duration/Character/Alleviating-Aggravating factors/Temporal pattern/Severity. Additional symptoms and previous treatment if known.
4. Medical history: PMH, FMH, SMH.
5. Social history, employment, habits, physical activity, allergies and medications taken. For these six elements include a concise statement about the impact of such findings for potential outcomes with in-text citations as required.
6. Review of systems.
7. As part the objective component include: Vital signs, body measurements.
8. Physical examination with pertinent normal findings, normal variations and abnormalities. Characterization of pain or discomfort (if present) and psychological status.
9. Completed or known diagnostic tests with results supporting or ruling outa medical diagnosis.
10. Diagnosis. Include a rationale and in-text citation supporting your diagnosis. Are there possible etiologies? What’s the reasoning behind it?(Include citations as required).
11. Differential diagnosis. Include three ruled out diagnoses with in-text citations supporting your ideas.
12. Treatment with rationales per therapeutic option. Describe the goals, priorities and education provided. Include a citation per therapeutic option and education.
13. New orders for diagnostic testing. Include rationale and one citation per order.
14. Follow ups and referrals if required.
15. Finish the case with a paragraph justifying a theoretical perspective supporting your management approach.