A 42-Year-Old Woman Comes to the Office Due to Increasing

A 42-year-old woman comes to the office due to increasing heartburn and regurgitation over the last 2 years.  Previously her symptoms only occurred after a large meal, but recently they have occurred almost daily.  She has had no dysphagia, odynophagia, weight loss, hematemesis, or melena.  The patient has no other medical issues and takes no medications.  She smokes cigarettes and drinks alcohol, although she has been cutting back on both.  The patient is a paralegal and describes her work as stressful.  Vital signs are within normal limits.  BMI is 28 kg/m².  The abdomen is nondistended, soft, and nontender with no hepatosplenomegaly.  The remainder of the physical examination is unremarkable and fecal occult blood testing is negative.  The patient says her symptoms are starting to affect her life and would like them to be controlled.  Which of the following is the most appropriate response to the patient regarding the next step in management?

A)"I need to do imaging studies to rule out gallstones."
B)"I need to monitor the pressure and pH within your esophagus."
C)"I will refer you to a gastroenterologist for an endoscopy."
D)"I will refer you to a surgeon for antireflux surgery evaluation."
E)"I will start a trial medication and see the response."

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