Gastroenterology Follow-Up Note

Subjective:

• Follow-up for refractory GERD and post-prandial epigastric dyspepsia.

• 45 y/o M reports persistent retrosternal burning and regurgitation x 3 mos despite daily PPI therapy. Symptoms 6/10 severity, worse post-prandially (spicy/fatty foods) and when supine; minimal relief with OTC antacids. Denies dysphagia, odynophagia, hematemesis, melena, N/V, fever, or unintentional weight loss. BMs regular, Bristol 4, daily.

• Omeprazole (Prilosec®) 20 mg PO daily; calcium carbonate (Tums®) 1,000 mg PO PRN; cholecalciferol (Vitamin D3) 1,000 IU PO daily.

• Diet high in caffeine (3 cups coffee/day) and late-night meals. Former smoker (quit 2018, 10 pack-years). EtOH: 4-5 beers/week. No recent travel. Works as a software engineer.

• PMH: HTN, obesity (BMI 32 kg/m²). PSH: Laparoscopic cholecystectomy (14/05/2019), uncomplicated. No prior endoscopies or GI hospitalizations.

Objective:

• Vitals (14:15): BP 128/82 mmHg, HR 74 bpm, Temp 36.8 °C, Wt 98 kg. Gen: NAD, A&O x3. Abd: Soft, non-distended, mild epigastric tenderness to deep palpation without rebound or guarding. Well-healed laparoscopic scars. Normoactive BS. No hepatosplenomegaly.

Assessment & Plan

• 1. Refractory Gastroesophageal Reflux Disease (GERD): DDx includes erosive esophagitis, peptic ulcer disease (PUD), H. pylori gastritis, eosinophilic esophagitis (EoE), Barrett's esophagus.
  • Probable poorly controlled GERD vs. H. pylori gastritis given persistent retrosternal burning and epigastric tenderness despite standard daily PPI.
  • Ensure proper PPI administration (30 mins prior to morning and evening meals); counselled on red-flag symptoms (dysphagia, melena, weight loss).
  • Order EGD with biopsy (rule out Barrett's, EoE, H. pylori) to be scheduled within 4 weeks.
  • Escalate omeprazole (Prilosec®) to 40 mg PO BID for acid suppression; counselled on potential side effects including headache, diarrhea, and long-term hypomagnesemia/B12 deficiency.
  • Elevate head of bed by 15 cm, avoid meals within 3 hours of bedtime, reduce caffeine and EtOH intake, and aim for 5-10% weight loss via regular aerobic exercise.
  • RTC in 6 weeks post-EGD to review histopathology and assess clinical response to BID PPI therapy.
  • Refer to registered dietitian for medical nutrition therapy regarding reflux triggers and weight management.
• 2. Hepatic Steatosis (Incidental finding on prior US): DDx includes metabolic dysfunction-associated steatotic liver disease (MASLD), alcoholic liver disease, drug-induced liver injury.
  • Likely MASLD secondary to obesity and metabolic risk factors; currently asymptomatic with no stigmata of chronic liver disease on exam.
  • Calculate FIB-4 score once baseline labs return to stratify fibrosis risk.
  • Order CMP, CBC, lipid panel, HbA1c, and FibroScan (transient elastography) to assess hepatic synthetic function and fibrosis stage.
  • No specific pharmacotherapy indicated at this stage; focus on metabolic optimization.
  • Strictly limit EtOH consumption to prevent synergistic hepatotoxicity; adopt Mediterranean diet and target 150 mins/week of moderate-intensity physical activity.
  • Review laboratory and FibroScan results at the scheduled 6-week follow-up visit.
  • Refer to hepatology or multidisciplinary metabolic clinic if FibroScan demonstrates advanced fibrosis (≥ F2).

Follow-up:

• Patient instructed to take omeprazole 30 minutes before breakfast and dinner, complete blood work this week, and await scheduling call for EGD and FibroScan. Return to clinic in 6 weeks (or sooner if experiencing difficulty swallowing, black tarry stools, persistent vomiting, or severe abdominal pain).