Abdominal Problems

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Case Study: 60-year-old patient

Patient Information: Name: Mary Johnson age: 60 Gender: Female Occupation: Retired.
Medical history: hypertension, osteoporosis
Presenting complaint: Mary Johnson presented to the primary care clinic with complaints of frequent
heartburn and acid regurgitation. She reported experiencing a burning sensation in her chest after
meals, and at night, especially when, lying down. She had been experiencing these symptoms for the
past six months and noticed that they worsened after consuming spicy or fatty foods. She also reported
occasional difficulty swallowing and a sour taste in her mouth.
Assessment: upon physical examination, Mary appeared in, no acute distress. Her vital signs were
stable:
Blood pressure: 130/ 80 mmHg
Heart rate: 70 bpm
respiratory rate: 16. Bmp
temperature: 36.8C (98.2F)
No abnormalities were found during a comprehensive physical examination.
Diagnostic work up:
1) Clinical evaluation:
Detailed patient history: confirmed the presence of classic symptoms of Gerd, including
heartburn, acid, regurgitation, and dysphasia.
Assessment of medication use: identified the use of nonsteroidal, anti-inflammatory
drugs, NSAIDs for arthritis pain,
2) Laboratory test:
Complete blood count [CBC]: within normal limits.
Liver function test: within normal limits.
Thyroid function test: within normal limits.
3) Imaging:
Upper gastrointestinal (GI) endoscopy: recommended to evaluate the severity of
esophageal, inflammation and exclude any structural abnormalities. This test Confirmed
the presence of erosive esophagitis and esophageal mucosal damage.
Diagnosis: Based on the clinical presentation, history, and endoscopic findings, Mary was diagnosed with
gastroesophageal efflux disease (GERD).

Questions:
1. Provide a detailed treatment plan for Mary based on her current diagnosis. Include in this
treatment plan: (give rationale for your answers)
All medications you would prescribe.
Lifestyle modifications.
Follow up and monitoring.
2. Provide a statement explaining the pathophysiology of GERD.
3. List 3 differential diagnosis that could be attributed to Marys symptoms

Sample Solution

Treatment Plan for Mary Johnson (60 years old) with GERD

Diagnosis: Gastroesophageal Reflux Disease (GERD)

Goals of Treatment:

  • Relieve symptoms of heartburn, acid regurgitation, and dysphagia.
  • Heal esophageal mucosal damage.
  • Prevent further complications from GERD.

Treatment Plan:

  1. Medications:
  • Proton Pump Inhibitor (PPI): This is the mainstay of treatment for GERD. PPIs work by reducing stomach acid production. Omeprazole, lansoprazole, or esomeprazole are common choices. Initial dosage will likely be 20mg once daily before breakfast. The rationale for PPIs is to directly address the root cause of GERD – excessive stomach acid production – promoting healing and symptom relief.
  • H2-Blocker (alternative): If PPIs are not tolerated or provide insufficient relief, an H2-blocker like famotidine or ranitidine can be considered. These medications also reduce stomach acid production but are less potent than PPIs.
  1. Lifestyle Modifications:
  • Diet:
    • Avoid trigger foods: Spicy, fatty, acidic foods (citrus, tomatoes), chocolate, peppermint, caffeine, and alcohol can worsen GERD symptoms. A food diary can help Mary identify her personal triggers.
    • Smaller, more frequent meals: Eating large meals can overwhelm the stomach and increase pressure on the lower esophageal sphincter (LES), leading to reflux. Smaller portions throughout the day can help.
    • Maintain a healthy weight: Excess weight puts pressure on the abdomen, contributing to GERD. Weight loss, if needed, can significantly improve symptoms.
  • Sleep habits: Elevate the head of the bed by 6-8 inches using wedges or blocks. This helps keep stomach acid from flowing back up the esophagus while sleeping.
  • Avoid tight clothing: Tight-fitting clothing around the waist can increase abdominal pressure and worsen reflux.
  • Smoking cessation: Smoking weakens the LES, making it easier for stomach acid to reflux. Quitting smoking is crucial for managing GERD.
  1. Follow-up and Monitoring:
  • Schedule a follow-up appointment in 4-8 weeks to assess response to treatment and adjust medication dosage or lifestyle modifications as needed.
  • Monitor for potential side effects of medications.
  • An upper endoscopy may be repeated in 6-12 months to assess healing progress, especially if symptoms persist despite treatment.

Rationale for Lifestyle Modifications:

Lifestyle modifications play a vital role in managing GERD. They address contributing factors and can significantly improve symptoms and reduce reliance on medications. They are also generally safer and have fewer side effects compared to long-term medication use.

Pathophysiology of GERD

GERD occurs when the lower esophageal sphincter (LES), a muscular valve at the junction of the esophagus and stomach, weakens or relaxes inappropriately. This allows stomach acid and contents to flow back (reflux) into the esophagus, causing irritation and inflammation of the esophageal lining.

Factors contributing to GERD include:

  • Increased stomach acid production
  • Hiatal hernia (part of the stomach pushes through the diaphragm)
  • Weakened LES
  • Delayed stomach emptying

Differential Diagnoses for Mary’s Symptoms

  1. Esophageal motility disorders: Conditions like achalasia or esophageal spasm can cause difficulty swallowing and chest pain that may mimic GERD symptoms.
  2. Peptic ulcers: Stomach ulcers can also cause heartburn and upper abdominal pain.
  3. Cardiac angina: Chest pain due to angina pectoris can sometimes be mistaken for heartburn, especially if it occurs after eating.

It’s important to perform a thorough clinical evaluation and consider these differential diagnoses to ensure an accurate diagnosis and appropriate treatment plan for Mary.

 

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