"My acid reflux is getting worse and my histamine blocker isn't working anymore. About an hour after a meal, I get a burning pain in the middle of my chest. Sometimes, I have trouble getting food down. It seems to get stuck behind my breastbone. I've never had that problem before. My heartburn is affecting my quality of life again and l want it to stop."
W.R. is a 75 yo male with a significant history of GERD. He presents to the family practice clinic today for a routine follow-up visit. The patient reports that during the past three weeks he has experienced increasing episodes of post-prandial heartburn with some regurgitation and dysphagia. He has also begun using antacids daily in addition to hislamine-2-receptor blockers for symptom relief. Despite sleeping with three pillows, the patient has also begun to experience frequent nocturnal awakenings from heartburn and regurgitation.
- HTN X 15 years
- GERD X 7 years
- Alcoholic cirrhosis X 2 years
- Hiatal hernia
FH
- Non-contributory
- Patient is widowed and lives alone; daughter lives in same town, checks on him regularly, and takes him grocery shopping every Saturday
- Patient is a retired college basketball coach
- Enjoys cooking, traveling, gourmet dining, and playing poker
- ( + ) caffeine; 5 cups coffee/day
- ( +) EtOH; history of heavy alcohol use; current EtOH consumption reported is 6 beers with shots/week
- ( + ) smoking; 55 pack-year history; currently smokes ¾ ppd
- Verapamil SR 120 mg po QD
- Hydrochlorothiazide 25 mg po QD
- Famotidine 20 mg po Q HS
All
- Citrus fruits and juices (upset stomach)
- Dogs (itchy eyes, runny nose, sneezing)
- Erythromycin (unknown symptoms)
- (-) H/A, dizziness, recent visual changes, tinnitus, vertigo
- (-) SOB, wheezing, cough, PND
- (+) frequent episodes of burning, non-radiating substernal CP
- (+) dysphagia
- (-) sore throat or hoarseness
- (-) N/V, diarrhea, BRBPR or dark/tarry stools
- (-) recent weight change
Gen
The patient is a pleasant, talkative Native American man who is wearing a sports jacket, jeans, and tennis shoes. He looks his stated age and does not appear to be in distress.
VS
See Patient Case Table 25.1 Vital Signs
Patient Case Table 25.1 BP 155/90 RR 18 and unlabored HT 5'8" P 75 and regular T 97.9°F WT 195 lbs
Skin
No rashes or lesions noted
HEENT
- PERRLA
- EOMI
- (-) arteriolar narrowing and A-V nicking
- Pink, moist mucous membranes
- (-) tonsils
- Oropharynx clear
lungs
CTA
Heart
- Regular rhythm
- (-) additional heart sounds
Abd
- Normoactive BS
- Soft, NT/ND
- (-) HSM
- (-) bruits
Genit/Rec
- (-) hemorrhoids
- (-) rectal masses
- Brown stool without occult blood
- Prostate WNL
Ext
(-) CCE
Neuro
- A & O for person, time, place
- CNs II-XII intact
- Strength 5/5 upper/lower extremities bilaterally
The patient underwent upper endoscopy, which revealed multiple, circular, confluent erosions of the distal esophagus. There was no evidence of bleeding, ulcerations, stricture, or esophageal metaplasia. The patient was treated with an 8-week course of 30 mg/day lansoprazole and both heartburn and dysphagia resolved. Approximately 10 weeks after PPI therapy was discontinued, the patient reported that his reflux symptoms had returned and that he was again suffering from frequent post-prandial and nocturnal episodes of reflux.
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Clinical Values for Case Study Problem-Solving
Abbreviations
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Abbreviations
Reference for digestion (or gastrointestinal)
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Gastrointestinal system diseases
© 2015 University of Washington | School of Nursing | Work is developed and designed for web by TIER Learning Technologies. From 100 case Studies in Pathophysiology.