The Comprehensive Medical Report

Title Your Name Subject and Section Professor’s Name Date This detailed medical report offers a summary of the patient's history, physical findings, diagnosis, treatment modalities, and recommendation for Gastro Esophageal Reflux Disease. Chief Complaint The patient has symptoms of heartburn regurgitation and dysphagia which is characteristic of gastro esophageal reflux disease. Medical History The patient has a history of repeated episodes of heartburn and regurgitation, for the past two weeks. The above symptoms have been gradually deteriorating over the last three days. The patient denies any remarkable noteworthy past medical history. Medication History The patient has been taking over-the–counter antacids irregularly for some symptomatic relief which gives a limited effect. There are no known drug hypersensitivities reported. Family History Apart from the family history of gastrointestinal disorders, no significant data is in this case. Physical Examination * Vital Signs: To be within the normal limits. * General Appearance: The patient looks well built and there is no immediate danger. * Abdominal Examination: Soft and non-tender no palpable masses or organomegaly. Diagnostic Testing * Esophageal Manometry: Not stated yet as the patient is not at present a candidate for surgical treatment (Maret-Ouda et al., 2020; MOC, 2020). * 24-Hour Ambulatory pH Monitoring: It is also considered as gold standard of diagnosis if symptoms are r...