1. CHIEF COMPLAINT •Dyspepsia 2. HPI 3. ROS 4. SYMPTOMS •Upper abdominal pain •Bloating •Fullness •Nausea •Early satiety •Abdominal distention 5. HISTORY •FAMILY HISTORY o Diabetes o Hypertension •SOCIAL HISTORY o Alcohol o Drugs o Tobacco •PASTMEDICAL HISTORY o Gastroesophageal reflux disease (GERD) o Gastritis o Peptic ulcer disease o Diabetes o Thyroid disease o Hyperparathyroidism •SURGICAL HISTORY •CHRONIC CONDITIONS o Diabetes o Thyroid disease o Hyperparathyroidism

6. ALLERGIES 7. PHYSICAL EXAMINATION •Tenderness on palpation 8. SPECIFIC DATA LIKE GRADING ETC 9. TESTS TO BE ORDERED •CBP •FBS •PLBS •Upper gastrointestinal endoscopy •Esophagram •Video-fluoroscopic swallowing study •Barium enema •Urea breath test •Abdominal ultrasonography (US) •CT scan •CAT scan •MRI •Esophageal motility study •Gastric emptying study •Electrogastrogram •Barostatic study •Small intestinal transit study •Antro-duodenal motility study •Gallbladder emptying studies 10.ASSESSMENT /PLAN •Psychological treatments include cognitive-behavioral therapy, hypnosis, psychodynamic or interpersonal psychotherapy, and relaxation/stress management. •Dietary changes including decreasing fat food, spices etc 11.EDUCATION 12.MEDICATION •Sucralfate •Tegaserod •Simethicone •Desipramine •Trimipramine

•Fluoxetine •Sertraline •Paroxetine •Cisapride •Erythromycin •Metoclopramide •Hyoscyamine •Methscopolamine •Ranitidine •Omeprazole •Lansoprazole •Rabeprazole •Pantoprazole •Esomeprazole 13.FOLLOW-UP

Sign up to vote on this title
UsefulNot useful