Phone GI procedure consult

Dear 

Thank you for referring  for evaluation.  is presenting with stomach pain and frequent heartburn.  reports experiencing a burning pain localized to the upper abdomen for the past few weeks, with heartburn occurring frequently, particularly after meals and exacerbated by spicy or fatty foods. Symptoms sometimes awaken  at night. Mild nausea is present.  denies vomiting, black stools, significant weight loss, or difficulty swallowing.

PAST MEDICAL HISTORY: 


MEDICATIONS:
The patient is currently taking over-the-counter antacids for symptom relief. 

ALLERGIES:


SURGICAL HISTORY: 


SOCIAL HISTORY: 


IMPRESSION:
 is presenting with symptoms most consistent with gastroesophageal reflux disease (GERD). The clinical findings include upper abdominal burning pain and frequent heartburn, partially responsive to antacids, with symptoms triggered by certain foods and occurring nocturnally. There are no alarm features such as gastrointestinal bleeding, significant weight loss, or dysphagia at this time. Peptic ulcer disease is also considered in the differential diagnosis. I have discussed the option of upper endoscopy if symptoms persist, including associated risks such as procedural complications. If indicated, further evaluation with endoscopy and H. pylori testing will be considered.

Thank you for this consultation. Please do not hesitate to contact me if further information is required.

Sincerely,

Alex Chen

This appointment was conducted via telehealth with the patient's consent. All patients are given the option to choose between in-person or virtual appointments.