Chronic Health GERD Comprehensive

Chronic Health: Comprehensive Case Study
Part A
Setting: Skilled nursing facility. The facility largely offers residential care for senior citizens – mostly from the age of 65 and above.
The patient is a 72-year-old Caucasian male who has been undergoing rehabilitation treatment, specifically orthopedic physical therapy, deemed necessary from a medical point of view.
Clinical information:
Chief complaint: Client complains of abdominal pain and “heartburn.”
HPI: Patient points out that he has been experiencing serious pain (described as burning) in his abdomen for the last 2 days. Pain originates from the midepigastric area. At its worst, the patient gives an 8/10 rating to the pain. The patient points out that he has been having similar pain – which comes and goes - over the last 3 weeks. Discomfort mainly experienced in night-time and after ingesting spicy foods. The patient denies vomiting, and also denies having suffered any kind of trauma in the recent past. The patient is not on any over-the-counter medications at present.
PMH: No known allergies. Was diagnosed with Type II diabetes at age 51. Denies any depression. Denies HTN.
PSH: Cholecystectomy
FH: Has been married for 36 years and has 3 children – 2 boys, 1 girl. Father – deceased (at 87 -HTN). Mother – deceased (at 70 - breast cancer). Patient is the eldest of four siblings who are all alive.
ROS: GENERAL: Denies fatigue, night sweats, malaise, as well as chills. Patient has not experienced any unexplained weight loss in the recent past. HEENT: Denies headaches or ear ringing. Denies cataracts or double vision. Denies sneezing, sinus pressure, or congestion in the nasal cavity. Denies difficulty in swallowing or sore throat. Patient has not experienced any unexplained variation in his sense of smell. SKIN: No skin abnormalities identified. CARDIOVASCULAR: Denies any palpations or chest pain. RESPIRATORY: No hemoptysis. No cough or wheezing. GASTROINTESTINAL: Denies diarrhea. Denies flatulence. Denies vomiting. Reports abdominal pain. GENITOURINARY: Denies any penile discharge. Denies hematuria and dysuria. MUSCULOSCELETAL: Reports joint pain. PSYCHIATRIC: No diagnosed mental condition. NEUROLOGICAL: Denies dizziness, loss of sensation, or memory loss. ENDOCRINE: Has history of diabetes.
PE: VITAL SIGNS: Patient BMI = 26.8; T = 97.9F; BP = 120/75 mm Hg; R = 16/min; HR = 80/min. GENERAL: The patients is, from a general perspective, well groomed. He also appears alert and oriented. NECK: supple, no JVD or bruit. LUNGS/CHEST: expansion symmetric. No adventitious sounds. HEART/PERIPHERAL VASCULAR: No murmurs. Regular rate as well as rhythm. ABDOMEN: non-distended and non-tender. Active and normal bowel sounds. MUSCULOSKELETAL: Spine straight. Negative paresthesia.
Diagnostic Testing: Upper endoscopy: esophagitis. Ambulatory 24-hour PH monitoring.
Medical Decision Making: The diagnosis was in this case made on the basis of not only the presenting symptoms and physical examination, but also upon confirmation from the relevant tests.
Diagnosis/Clinical Impression: Gastroesophageal reflux disease (GERD). Differential Diagnosis: Acute gastritis
Plan/Interventions: A stepwise approach will be embraced with the overall objectives being prevention of recurrent esophagitis, ensuring that the esophagitis heals, and controlling the symptoms presently exhibited.
Given that the symptoms that the patient presents with are in this case moderate, it would be prudent to start him off with first-line agents. It is also important to note that on the basis of the fact that multiple folds appeared to be affected by multiple erosions, the patient has grade II esophagitis. Towards this end, H2 blocker therapy will be started. This will also come in handy given that the patient has reported that discomfort is mostly experienced in night time (i.e. nocturnal acid breakthrough). Considerations on this front could be inclusive of cimetidine (Tagamet), famotidine (Pepcid AC), and nizatidine (Axid).
Antacids will be given concomitantly. Antacids are effective in the neutralization of stomach acid. Considerations on this front could be inclusive of, but they are not limited to, Rolaids, Tums, and Mylanta.
Recommendations:
Famotidine 20mg. To be taken twice daily. To be taken for a maximum of 6 weeks. The lower dosage has in this case been selected owing to the age of the patient. At 72 years of age, the patient’s kidneys may not be as effective – effectively meaning that drugs are processed slowly than usual. Towards this end, there is need to prevent the levels of the prescribed medication from building up in the body by starting the patient off on a lower dosage.
Tums (Calcium 500mg). Chew 2-4 tablets a day as symptoms occur. 2 weeks max. 15 tabs max/day.
Education: The patient will be advised on not only how the medications work, but also the associated side effects, as well as contraindications. In essence, the medications will help in lowering acid secretion and neutralizing stomach acid. They will also come in handy in the healing of esophageal erosions. The patient will most likely experience mild side effects. These side effects are, however, expected to subside with continued taking of the medications. Side effects on this front could be inclusive of, but they are not limited to; a runny nose, dry skin and mouth, difficulty sleeping, and diarrhea or constipation. The patient will be advised to seek immediate medical attention if he experiences more severe side effects such as hallucinations, difficulty in breathing, confusion, vision changes, and scaling or blistered skin.
Patent will be advised to stick to the dosage recommendation for antacids. This is more so the case given that need to avoid acid rebound. In essence, acid rebound has been associated with the lengthy as well as high dosage consumption of antacids.
In as far as famotidine is concerned, no significant drug interactions have been noted. The drug was specifically selected owing to the fact that the patient is on diabetic medications.
Health promotion: The relevance of dietary and lifestyle adjustments cannot be overstated when it comes to the treatment of GERD. Towards this end, the patent will be advised accordingly on the said adjustments so as to ensure that symptoms are alleviated, while at the same time promoting long-term wellbeing. The most important patient-specific changes and modifications have been highlighted below:
1. Weight loss. As per the patient’s BMI, he appears to be overweight (with a BMI of 26.8). The objective would in this case be to maintain the patient’s BMI between 18.5 and 24.9. Studies have indicated that there is a relationship between a reflux of acid into the esophagus and excess pounds.
2. Smoking cessation. The patient also ought to stop smoking as available research indicates that ability of the esophageal sphincter to function normally is decreased by cigarette smoking.
3. Avoid certain foods and beverages. There are certain foods and beverages that have been associated with the relaxation of the lower esophageal sphincter (LES). The said foods and beverages are inclusive of, but they are not limited to; fatty foods, peppermint, alcoholic drinks, and caffeine. The patient will be advised to avoid these. This is particularly important given that the patient’s family indicates that he occasionally takes beer. The patient should also do away with tomato products as well as citrus juice/fruits as they could do more harm to an esophageal lining that is already damaged.
4. Loose clothing: The patient will be advised that tight clothing could pressurize his waist as well as his lower esophageal sphincter.
5. Head elevation: The patient has reported that his discomfort is mainly experienced in night time. Towards this end, he will be advised to ensure that he sleeps with his head elevated by approximately 8 inches. This he could do by placing cement (or wood) blocks under the feet of his bed. This would help by lowering the chances of stomach contents refluxing into the esophagus. As a cautionary measure, the patients should be advised NOT to use pillows towards this end as this has the ability to pile up more stomach pressure.
6. Additional Recommendations: In addition to ensuring that he chews his food thoroughly before swallowing, the patient will also be advised against going to bed (or lying down) immediately after having a meal. He should allow for at least 3 hours before either retiring to bed or lying down. This is beneficial as it allows for stomach acid to go down. It is also important to note that symptoms could be alleviated by having smaller servings as opposed to big meal portions.
Additional info sourced from family members:
The patient has a strong family support system comprising of his 57 year old wife and 3 grownup children. The patient’s wife is a retired nurse while all his children are gainfully employed and financially stable. The patient is alert, adheres to instructions, and is attentive. He is a Roman Catholic but is not deeply religious (attends church only occasionally). The patient is an avid reader – with his family describing him as a ‘book with two legs sticking out’ due to his constant reading habits. He is an effective communicator and has a rich sense of humor. His family indicates that he loves his beer and smokes occasionally (about thrice a week).
Part B (Evidence-Based Research on Interventions Selected)
From the onset, it is important to note that as Chait (2010) points out, GERD happens to be rather common among the elderly. As a matter of fact, as the author further points out, it is the most frequent gastrointestinal disorder in this particular population. According to Jeffrey and Timothy (2018), histamine (H2) blockers come in handy in not only the reduction of GERD symptoms, but also in the improvement of life quality. More specifically, in the words of the authors, GERD patients who are exposed to treatment with histamine (H2) blockers happen to be “16% to 23% more likely to have heartburn remission, 20% to 25% more likely to have pain-free days, and 28% to 69% more likely to have improvement in overall symptoms compared with patients treated with placebo” (15). The H2 receptor blocker was selected over PPIs on the basis of available research indicating that the latter could be more effective than the former in some instances (or as an add-on to PPI therapy) (Wang, et al., 2013). To a large extent, both proton pump inhibitors (PPIs) and H2 receptor blockers (also referred to as histamine H2-receptor antagonists) function by reducing as well as blocking stomach acid production. Although PPIs are deemed stronger in this role, H2 receptor blockers are particularly effective - especially in the evening. In the present scenario, the patient reports that discomfort is mainly experienced in night time. Further, it should also be noted that as Wang et al. (2013) observe, “refractory GERD, defined as reflux symptoms either completely or incompletely responsive to PPI therapy, has become an important issue in clinical practice” (p. 78). Towards this end, it could be deemed prudent to incorporate H2 receptor blockers into the treatment equation. However, it is also important to note that as Sandhu and Fass (2017) point out, alongside the appropriate medical therapy, the relevance of lifestyle modifications cannot also be overstated when it comes to the management of GERD.
References
Chait, M. (2010). Gastroesophageal reflux disease: Important considerations for the older patients. World J Gastrointest Endosc., 2(16), 388-396.
Jeffrey, Q. & Timothy, M. (2018). In adult patients with GERD, do histamine (H2) blockers reduce symptoms and improve quality of life? Evidence-Based Practice, 21(1), 11-18.
Sandhu, D.S. & Fass, R. (2017). Current Trends in the Management of Gastroesophageal Reflux Disease. Gut Liver, 12(1), 7-16.
Wang, Y., Hsu, W., Wang, S.S., Lu, C., Kuo, F., Su, Y., …Kuo, C. (2013). Current Pharmacological Management of Gastroesophageal Reflux Disease. Gastroenterology Research Practice, 4(1), 73-79.