S – Subjective

Chief Complaint:

“Heartburn and acid regurgitation.”

History of Present Illness:

The patient is a 45-year-old male who presents with a burning sensation behind the chest and sour taste in the mouth for the past 3 weeks.
Symptoms occur mainly after meals and when lying down, and are partially relieved by antacids.
He denies chest pain radiating to the arm or jaw, shortness of breath, vomiting, or fever.

Associated symptoms:

• (+) Acid regurgitation

• (+) Postprandial discomfort

• (–) Dysphagia

• (–) Hematemesis

• (–) Melena

• (–) Unintentional weight loss

Past Medical History:

No known chronic medical conditions.

Medications:

Occasional over-the-counter antacids.

Allergies:

No known drug allergies.

Social History:

Drinks coffee daily. Occasional alcohol use. Non-smoker.

O – Objective

Vital Signs:

• BP: 125/80 mmHg

• HR: 76 bpm

• RR: 16 /min

• Temp: 36.8°C

• SpO₂: 98% on room air

General:

Patient is alert, oriented, and in no acute distress.

Abdominal Exam:

Abdomen soft, non-distended.
Mild epigastric tenderness, no guarding or rebound.
Bowel sounds present.

Cardiopulmonary:

Normal S1/S2, no murmurs. Lungs clear bilaterally.

A – Assessment

1. Gastroesophageal reflux disease (GERD) – most likely

2. Gastritis / Functional dyspepsia – differential diagnosis

No alarm features at this time.

P – Plan

Medications

• Start Proton Pump Inhibitor (PPI) once daily before breakfast
  (e.g., Omeprazole 20 mg PO daily)

Lifestyle Modifications

• Avoid spicy, fatty foods, caffeine, and alcohol

• Eat smaller, more frequent meals

• Avoid lying down within 2–3 hours after meals

• Elevate head of bed if nighttime symptoms occur

Patient Education

Explained the mechanism of acid reflux and expected response to treatment.
Patient verbalized understanding.

Follow-up

• Reassess symptoms in 4–6 weeks

• Consider upper endoscopy if symptoms persist or alarm signs develop

Return Precautions

Instructed to return immediately for dysphagia, persistent vomiting, GI bleeding, or weight loss.

PRACTICE SPEECH – GERD / GASTRITIS

“Hello, I’m Dr. Trung.
Today, I’m going to assess a patient presenting with heartburn and acid-related symptoms.

First, I would like to clarify /ˈklærəfaɪ/  the main complaint and its duration.
I would ask what symptoms brought the patient in and how long they have been experiencing them.

Before focusing on gastrointestinal causes, patient safety is my priority.
I would screen for cardiac red flags by asking about chest pain radiating to the arm or jaw, shortness of breath, dizziness /ˈdɪzinəs , or fainting /feɪnt/ .
If these are absent /ˈæbsənt/ , I would proceed /prəˈsiːd/  with a focused gastrointestinal history.

I would then explore symptoms suggestive of acid reflux /ˈriːflʌks/ , including a burning sensation behind the chest, a sour /ˈsaʊər/  or bitter taste in the mouth, and regurgitation /rɪˌɡɜːrdʒɪˈteɪʃn/  of food or liquid.
I would ask whether the symptoms worsen after meals or when lying down, especially at night.

Next, I would assess for gastritis or dyspepsia by asking about pain or burning in the upper abdomen, bloating, nausea, early fullness, and whether symptoms are related to meals or hunger.

I would carefully screen for alarm features, including difficulty swallowing, vomiting blood, black stools, unintentional weight loss, or persistent vomiting, as these would change management significantly.

After history taking, I would explain the examination, obtain consent /kənˈsent/ , and perform an abdominal exam, paying particular attention to the epigastric area.

Based on the clinical presentation, if the patient has heartburn and regurgitation without alarm signs, my leading diagnosis would be gastroesophageal reflux disease, possibly with features of gastritis.

I would explain this clearly to the patient, reassure them that there are no concerning signs at this time, and outline a management plan including acid-suppressing medication and lifestyle modifications.

Finally, I would advise follow-up, provide safety-net instructions, and invite any questions or concerns from the patient.”