Patient is a 21 y/o male with GERD without esophagitis, who came to discuss test results, abdominal US was within normal limits, he indicates was seen by Gastroenterologist, who ordered H pylori test which was negative, he also ordered Omeprazole 40gm PO + Sucralfate for 3 months, and will consider endoscopy if symptoms to not improve. Lifestyle modification and dietary changes was recommended, patient education provided. We will follow up as needed. Patient report has been experiencing A burning sensation in the abdomen often after eating, which sometimes get worse at night or when lying down.
Diagnosis: K21.9
