Chapter 3: The Digestive System | Ida Gundrum's Chart Note

CHART NOTE

Patient Name: Gundrum, Ida
ID Number: 98774
Examination Date: October 11, 20xx

SUBJECTIVE
29-year-old female complains of epigastric discomfort, which she describes as a constant burning for several weeks. Initial treatment was successful with Tagamet® (drug that reduces gastric acid secretions), but discomfort has recurred several times over a 2-week period. She complains of nausea. No vomiting or hematemesis. Tagamet® partially relieves her symptoms. She has been under considerable stress at work due to job downsizing and outsourcing of personnel. Headache relief in the form of Tylenol® or Motrin® has been unsuccessful and seems to exacerbate (worsen) her condition.

OBJECTIVE
Abdomen is soft, flat, and nontender with normal bowel sounds. No masses or organomegaly.

ASSESSMENT
Gastritis, probably exacerbated by NSAIDs (nonsteroidal anti-inflammatory drugs), and stress.

PLAN
We discusssed several methods of stress reduction, including support group websites. She will stop using Motrin® or Tylenol® for headaches. She was given a sample of Prilosec® 20mg q.i.d. (4 times a day) to be taken for one month. The patient will return in 3—4 weeks for a follow-up visit.