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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Describe the clinical presentation of gastroesophageal reflux disease (GERD), including typical, atypical, and alarm symptoms.

  • Discuss appropriate diagnostic approaches for GERD, including when patients should be referred for further diagnostic evaluation.

  • Recommend appropriate nonpharmacologic and pharmacologic measures for treating GERD.

  • Develop a treatment plan for a patient with GERD, including both nonpharmacologic and pharmacologic measures and monitoring for efficacy and toxicity of selected drug regimens.

  • Outline a patient education plan for proper use of drug therapy for GERD.

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PATIENT PRESENTATION

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Chief Complaint

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“I’m having a lot of heartburn. These pills I have been using have helped a little but it’s still keeping me up at night.”

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HPI

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Janet Swigel is a 68-year-old woman who presents to the GI clinic with complaints of heartburn four to five times a week over the past 5 months. She also reports some regurgitation after meals that is often accompanied by an acidic taste in her mouth. She states that her symptoms are worse at night, particularly when she goes to bed. She finds that her heartburn worsens and she coughs a lot at night, which keeps her awake. She has had difficulty sleeping over this time period and feels fatigued during the day. She reports no difficulty swallowing food or liquids. She has tried OTC Prevacid 24HR once daily for the past 3 weeks. This has reduced the frequency of her symptoms to 3–4 days per week, but they are still bothering her.

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PMH

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  • Atrial fibrillation × 12 years

  • Asthma × 10 years

  • Type 2 DM × 5 years

  • HTN × 10 years

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SH

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Patient is married with three children. She is a retired school bus driver. She drinks one to two glasses of wine 4–5 days per week. She does not use tobacco. She has commercial prescription drug insurance.

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FH

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Father died of pneumonia at age 75; mother died at age 68 of gastric cancer

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MEDS

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Diltiazem CD 120 mg PO once daily

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Hydrochlorothiazide 25 mg PO once daily

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Metformin 500 mg PO twice daily

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Aspirin 81 mg PO daily

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Fluticasone/salmeterol DPI 100 mcg/50 mcg one inhalation twice daily

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All

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Peanuts (hives)

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ROS

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Reports being tired all the time, (–) SOB or hoarseness; (+) cough at night, (+) frequent episodes of heartburn, sometimes after meals, but is worse at night; (–) N/V; (–) BRBPR or dark/tarry stools; (–) dysuria, nocturia, or frequency

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Physical Examination

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Gen
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Well-developed African-American woman ...

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