Gastroenterology Follow Up Note

Dear Dr. 

The patient was seen in follow-up via in person visit on January 13, 2026.

Reason for follow-up: Follow-up for acid reflux management

Interval:
The patient reports significant improvement in heartburn symptoms since starting medication. Only a mild headache is noted as a possible side effect, which is not severe. The patient states adherence to dietary recommendations, avoiding spicy and fatty foods most of the time.

Current Medications:
The patient is currently taking medication for acid reflux.

Assessment:
Acid reflux symptoms are well controlled on the current medication regimen. The patient experiences only mild, non-limiting headaches as a possible side effect. The patient is compliant with dietary modifications.

Plan and Recommendations:
1. Acid reflux: Continue current medication regimen for acid reflux. Maintain avoidance of spicy and fatty foods.

Follow-Up:
Follow up in three months unless symptoms return.

Thank you for involving us in this patient’s care.

Note: This dictation was created with voice recognition software and circulated immediately to facilitate care. If there are more than minor errors, please inform the author.