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Posted: April 4th, 2019
Diagnosis and Management of Gastrointestinal Disorders
Case Study 2
Victoria is a 15-year-old who complains of chronic sore throat and bad taste in her mouth. Her height and weight are appropriate for age and she remains on the same growth trajectory since infancy. Abdominal examination and chest examination are negative. History reveals frequent burping and occasional feelings of regurgitating food. Diet history reveals she eats a balanced diet, but her primary sources of fluids are coffee, tea, and carbonated drinks.
To Prepare
• Review “Gastrointestinal Disorders” of the Burns et al. text.
• Review and select one of the three provided case studies. Analyze the patient information.
• Consider a differential diagnosis for the patient in the case study you selected. Think about the most likely diagnosis for the patient.
• Think about a treatment and management plan for the patient. Be sure to consider appropriate dosages for any recommended pharmacologic and/or non-pharmacologic treatments.
• Consider strategies for educating patients and families on the treatment and management of the gastrointestinal disorder
By Day 3
1. Post an explanation of the differential diagnosis for the patient in the case study you selected.
2. Explain which is the most likely diagnosis for the patient and why. Include an explanation of unique characteristics of the disorder you identified as the primary diagnosis.
3. Then, explain a treatment and management plan for the patient, including appropriate dosages for any recommended treatments.
4. Finally, explain strategies for educating patients and families on the treatment and management of the gastrointestinal disorder.
___________________Diagnosis and Management of Gastroesophageal Reflux Disease
Introduction
This paper presents the case of Victoria, a patient experiencing gastrointestinal issues including an undesirable taste in her mouth, chronic sore throat, frequent burping and regurgitation. These symptoms suggest the potential diagnoses of Gastroesophageal Reflux Disease (GERD) or hiatal hernia.
Diagnosis
To confirm the diagnosis, upper endoscopy would be recommended. This procedure allows direct visualization of the esophagus, stomach, and first part of the small intestine to detect any abnormalities. Findings such as esophagitis or a hiatal hernia would support a diagnosis of GERD (PubMed, 2022).
Victoria’s history of heartburn, regurgitation of acid/food, and exacerbation of symptoms after eating are all classic presentations of GERD (NHS, 2022). Her daily coffee consumption could aggravate reflux by relaxing the lower esophageal sphincter (PubMed, 2021). While hiatal hernia may be present, on balance the primary diagnosis is GERD rather than a hernia or Irritable Bowel Syndrome, as IBS does not typically cause heartburn or regurgitation.
Treatment and Management
Lifestyle modifications are central to treatment, such as elevating the head of the bed, small frequent meals, weight loss if overweight, and avoiding trigger foods like citrus, tomato, mint, garlic and caffeine after meals (NICE, 2022). Pharmacological options include antacids, H2 blockers and proton pump inhibitors under medical supervision (PubMed, 2020). Surgery may be considered for severe cases unresponsive to other measures.
With adherence to lifestyle changes and medication if needed, Victoria’s GERD symptoms can be effectively managed. Please let me know if any part of the diagnosis or treatment plan requires further explanation or modification.
References:
NHS. (2022). Gastro-oesophageal reflux disease. https://www.nhs.uk/conditions/gastro-oesophageal-reflux-disease-gord/
NICE. (2022). Gastro-oesophageal reflux disease and dyspepsia in adults. https://www.nice.org.uk/guidance/ng1
PubMed. (2020). Proton pump inhibitors for gastroesophageal reflux disease. https://pubmed.ncbi.nlm.nih.gov/32183856/
PubMed. (2021). Caffeine and gastroesophageal reflux disease. https://pubmed.ncbi.nlm.nih.gov/33503933/
PubMed. (2022). Endoscopy in gastroesophageal reflux disease. https://pubmed.ncbi.nlm.nih.gov/34941659/
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