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Posted: March 21st, 2022
GERD Case Study Week 7
GERD Case Study Week 7
PATIENT CASE Patient’s Chief Complaints “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 I want it to stop.” HPI 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 histamine-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. PMH HTN × 15 years GERD × 7 years Alcoholic cirrhosis × 2 years Hiatal hernia
FH Non-contributory
SH Patient is widowed and lives alone; daughter 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
Meds Verapamil SR 120 mg po QD Hydrochlorothiazide 25 mg po QD Famotidine 20 mg po Q HS Allergy
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Week 7 GERD Case Study
Week 7 GERD Case Study
CASE OF A PATIENT Principal Complaints of the Patient “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 I want it to stop.” HPI 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
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