GERD Case Study: Elderly Patient Management in SNF
This case study examines the diagnosis and evidence-based management of gastroesophageal reflux disease (GERD) in a 72-year-old Caucasian male residing in a skilled nursing facility. Part A presents a full clinical workup — including chief complaint, history of present illness, review of systems, physical examination, diagnostic testing, and a stepwise treatment plan featuring famotidine and antacid therapy. Patient education, medication safety considerations related to renal function and age, and six targeted lifestyle and dietary recommendations are also detailed. Part B situates the chosen interventions within current research, justifying the selection of H2 receptor blockers over proton pump inhibitors given the patient's predominantly nocturnal symptoms and type II diabetes history.
- Clinical Presentation and Patient History: Chief complaint, HPI, PMH, and family history
- Physical Examination and Diagnostic Testing: Vital signs, PE findings, and endoscopy results
- Diagnosis and Treatment Plan: GERD diagnosis, H2 blocker, and antacid therapy
- Patient Education and Medication Safety: Side effects, dosage guidance, and drug interactions
- Health Promotion and Lifestyle Modifications: Six targeted dietary and behavioral recommendations
- Evidence-Based Rationale for Selected Interventions: Research support for H2 blockers over PPIs
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What makes this paper effective
- The case is organized with genuine clinical structure — chief complaint, HPI, PMH, ROS, PE, diagnostics, plan — mirroring real SOAP-note and clinical documentation standards, which makes the paper immediately credible and readable.
- Treatment decisions are explicitly justified: the lower famotidine dose is tied directly to the patient's age and reduced renal clearance, demonstrating pharmacokinetic reasoning rather than rote prescription.
- Part B strengthens Part A by anchoring every major intervention to peer-reviewed sources, with direct quotation of outcome statistics, showing how clinical decision-making maps to the evidence base.
Key academic technique demonstrated
The paper demonstrates evidence-to-practice translation: clinical choices made in Part A are retroactively grounded in quantitative research findings in Part B. The use of a direct statistical quotation from Jeffrey and Timothy (2018) — citing percentage improvements in heartburn remission — exemplifies how student clinicians should anchor treatment rationale in measurable outcomes rather than general claims.
Structure breakdown
The paper is divided into two complementary parts. Part A follows a standard clinical case format covering patient demographics, symptom history, systems review, physical findings, diagnostic results, diagnosis with differential, a specific stepwise treatment plan, patient education, and lifestyle counseling. Part B shifts to an academic literature review mode, citing four peer-reviewed sources to validate the therapeutic choices made in Part A. Together, the two parts model the bridge between clinical practice and scholarly evidence.
Clinical Presentation and Patient History
Setting: Skilled nursing facility. The facility primarily offers residential care for senior citizens, mostly aged 65 and above.
The patient is a 72-year-old Caucasian male who has been undergoing rehabilitation treatment — specifically orthopedic physical therapy — deemed medically necessary.
Chief Complaint: The client complains of abdominal pain and "heartburn."
History of Present Illness (HPI): The patient reports serious burning pain in his abdomen for the past two days. The pain originates from the midepigastric area and is rated 8/10 at its worst. He notes that similar pain — intermittent in nature — has been occurring over the past three weeks. Discomfort is experienced mainly at night and after eating spicy foods. The patient denies vomiting and denies any recent trauma. He is not currently taking any over-the-counter medications.
Past Medical History (PMH): No known allergies. Diagnosed with Type II diabetes at age 51. Denies depression. Denies hypertension (HTN).
Past Surgical History (PSH): Cholecystectomy.
Family History (FH): Married for 36 years; has three children (two sons, one daughter). Father deceased at age 87 (HTN). Mother deceased at age 70 (breast cancer). Patient is the eldest of four siblings, all of whom are alive.
Review of Systems (ROS):
General: Denies fatigue, night sweats, malaise, and chills. No unexplained weight loss.
HEENT: Denies headaches or ear ringing. Denies cataracts or double vision. Denies sneezing, sinus pressure, or nasal congestion. Denies difficulty swallowing or sore throat. No unexplained changes in sense of smell.
Skin: No skin abnormalities identified.
Cardiovascular: Denies palpitations or chest pain.
Respiratory: No hemoptysis, cough, or wheezing.
Gastrointestinal: Denies diarrhea, flatulence, or vomiting. Reports abdominal pain.
Genitourinary: Denies penile discharge, hematuria, and dysuria.
Musculoskeletal: Reports joint pain.
Psychiatric: No diagnosed mental condition.
Neurological: Denies dizziness, loss of sensation, or memory loss.
Endocrine: History of diabetes.
Physical Examination and Diagnostic Testing
Vital Signs: BMI = 26.8; Temperature = 97.9°F; BP = 120/75 mmHg; Respiratory Rate = 16/min; Heart Rate = 80/min.
General: The patient is well groomed, alert, and oriented.
Neck: Supple; no jugular venous distension (JVD) or bruit.
Lungs/Chest: Expansion symmetric; no adventitious sounds.
Heart/Peripheral Vascular: No murmurs; regular rate and rhythm.
Abdomen: Non-distended and non-tender; active and normal bowel sounds.
Musculoskeletal: Spine straight; negative paresthesia.
Diagnostic Testing: Upper endoscopy revealed esophagitis. Ambulatory 24-hour pH monitoring was also performed.
Medical Decision Making: The diagnosis was made on the basis of presenting symptoms, physical examination findings, and confirmation from the relevant diagnostic tests.
Diagnosis / Clinical Impression: Gastroesophageal reflux disease (GERD).
Differential Diagnosis: Acute gastritis.
Diagnosis and Treatment Plan
A stepwise approach will be embraced with three overall objectives: prevention of recurrent esophagitis, promotion of esophagitis healing, and control of currently exhibited symptoms.
Given that the patient presents with moderate symptoms, it is prudent to initiate first-line agents. It should also be noted that multiple erosions appeared to affect multiple folds on endoscopy, indicating grade II esophagitis. Accordingly, H2 blocker therapy will be initiated. This is particularly appropriate given the patient's report that discomfort is experienced mainly at night (i.e., nocturnal acid breakthrough). Considerations include cimetidine (Tagamet), famotidine (Pepcid AC), and nizatidine (Axid).
Antacids will be administered concomitantly, as they are effective in neutralizing stomach acid. Options include, but are not limited to, Rolaids, Tums, and Mylanta.
Specific Recommendations:
Famotidine 20 mg — to be taken twice daily for a maximum of six weeks. The lower dosage has been selected in consideration of the patient's age. At 72 years, the patient's kidneys may not process medications as efficiently as in younger adults, meaning drugs are cleared more slowly than usual. A lower starting dose reduces the risk of medication accumulation in the body.
Tums (Calcium Carbonate 500 mg) — chew 2–4 tablets per day as symptoms occur, for a maximum of two weeks. No more than 15 tablets per day.
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