MASLD Consult note

Thank you for referring this patient with suspected dyspepsia and possible gastroesophageal reflux disease (GERD). The patient was evaluated in-person today.

IMPRESSION & PLAN: 
Patient with several weeks of postprandial upper abdominal pain, bloating, nausea, and heartburn, with a history of mild heartburn and a significant family history of colon cancer. I explained to the patient that these symptoms are suggestive of dyspepsia or GERD. I would like to exclude other contributors to his symptoms and will arrange a panel of bloodwork.

We discussed that the mainstay of treatment is lifestyle modification with diet and meal pattern changes, with a goal of symptom management. I advised avoidance of spicy and fatty foods, alcohol, and NSAIDs such as Advil. I recommended smaller, more frequent meals. I prescribed acid-reducing medication.

Regarding NSAID usage, I recommended avoidance due to the potential for gastrointestinal irritation.

The patient will be sent for blood work, upper endoscopy to evaluate the stomach lining, and testing for Helicobacter pylori infection. Follow-up will be arranged in two weeks to review test results and reassess symptoms.

Thank you for involving me in your patient's care.

Mr. Johnson has known of their symptoms for the past few weeks. They believe this was identified in the context of postprandial pain and bloating.

The patient overall feels well and denies vomiting, blood in stool, black, tarry stools, weight loss, or changes in bowel movements.

PAST MEDICAL HISTORY:
History of mild heartburn several years ago.

MEDICATIONS:
Occasionally takes Advil (ibuprofen) for headaches.

ALLERGIES:

RISK FACTORS FOR LIVER DISEASE:

FAMILY HISTORY:
Father had colon cancer in his 60s.

SOCIAL HISTORY:

PHYSICAL EXAM:

INVESTIGATIONS: