Acid Reflux

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents with a ‍-‍day history of ‍acid reflux

Symptoms include:

‍heartburn

‍regurgitation

‍chest pain, ‍retrosternal, ‍aching, ‍on exertionat restwith deep breath, ‍mild

‍cough, ‍non-productiveproductive of ‍clearcolored phlegm

‍belching

‍sore throat

‍hoarseness

‍sour taste in mouth

‍dysphagia

‍bloating

‍nausea



Worsening factors: ‍none

Alleviating factors: ‍none, ‍effectiveineffective



Contributing factors:

‍obesity

‍pregnancy

‍smoking

‍alcohol intake

‍stress

no history of: ‍GERD, ‍hiatus hernia, ‍peptic ulcer disease

no use of: ‍NSAID, ‍aspirin, ‍PPI, ‍anti-acids





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Throat: ‍normal, ‍erythema, ‍exudate, ‍

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍guarding, bowel sounds ‍normal, ‍, ‍CVA tenderness ‍





ASSESSMENT:

‍GERD ‍likelysuspectedpossible

DDx: GERD, non-erosive reflux disease, erosive esophagitis, functional heartburn, Barrett's esophagus, hiatal hernia, gastroparesis, gastritis, peptic ulcer disease, Zollinger-Ellison syndrome, esophageal motility disorders, esophageal stricture, esophageal cancer, laryngopharyngeal reflux, acute coronary syndrome, eosinophilic esophagitis, pill esophagitis





PLAN:

Investigations:

- Upper GI endoscopy

Treatments:

- Dietary modifications (avoid spicy foods, caffeine, alcohol)

- Avoid eating 2-3 hours before bedtime

- Elevate head of bed

- Weight loss counseling

- Smoking cessation counseling

- ‍PPIs

- ‍Ranitidine

- ‍Sucralfate

- Over-the-counter anti-acids

Further care:

- Referral to gastroenterologist

- Follow-up in ‍ months

- Return if symptoms worsen or if new symptoms develop