Respond to the 2 following posts separately with separate reference lists. References to be no older than 5 years.
1. [Leslie Garcia]
6-year-old male complains of chest pain described as pain in his midchest for the past couple of months that has progressively worsened over the last couple of weeks. He states it has worsened when he is going to bed at night or when he eats a large meal. He has been eating out a lot more over the past couple of months because he has been traveling a lot for work. He denies any nausea or vomiting. He has been taking OTC Tums for the past few weeks, but he has to take 10-12 a day and only gets minimal relief. He denies any unusual weight gain or loss. Physical exam reveals an obese, Caucasian male with mild epigastric tenderness. No hepatosplenomegaly. Bowel sounds normoactive in all four quadrants. Provide the most likely diagnosis based on the HPI and PE. In addition, provide your interpretation of the cues found in the assessment. List at least 3 possible differential diagnoses and justify your rationale. Develop therapeutic plan options based on quality, evidence-based clinical guidelines.
Diagnosis and interpretation
The patient in this case is most likely suffering from Gastroesophageal Reflux Disease (GERD). The classic and most common symptom of GERD is heartburn. The main symptom of GERD is heartburn, which is a burning sensation in the chest, or chest pain that radiates toward the mouth which happens from acid reflux into the esophagus (Clarett, 2018).
The reason why I believe it is GERD, is through interpretation of the cues found in the assessment. The first one was that his pain is worse when going to bed or after eating a large meal. According to Taraszewska (2021), there is research that shows fatty, fried, spicy foods are some of the foods that can cause GERD as well as irregular eating patterns, large meals, or eating before going to sleep. During the assessment, it was found that the patient has been eating out a lot for the last couple of months, and typically, eating out consists of fried fatty foods. Second, he is an obese, and excess body weight, is a risk factor for GERD (taraszewska, 2021). This patient has also been taking Tums and it has been somewhat relieving, indicating some extent of reflux disease. Lastly, the assessment showed epigastric tenderness with no hepatosplenomegaly, and active bowel sounds. Epigastric tenderness is a typical symptom of GERD.
Differential Diagnosis
GERD (ICD 10: K29.1):
Based on the patient’s “heartburn”-like symptoms, and the fact that he has been eating out frequently due to travel would lead to suggest GERD. The patient also admits to take tums to help relieve the pain with minimal relief suggests his GERD is severe. He also has been getting the “chest pain” coincidently after eating a large meal and during the night which is also suggestive of GERD.
Peptic ulcer (ICD 10: K27.9)
Patients with Peptic ulcer disease sometimes have similar symptoms to GERD. Symptoms include epigastric abdominal pain, burning, or early satiety when eating, and worsening abdominal pain on an empty stomach (Narayana, 2018). The patient only has the pain after eating and not on an empty stomach so this possibility is ruled out
Esophageal Spasm (ICD 10: K22.4)
Esophageal spasms is a disease that is caused by spontaneous contractions or spasms of the esophageal sphincter. It causes patients to have symptoms such as sudden chest pain and difficulty swallowing during eating, eventually sensing the passage of food to the stomach (Gorti et al., 2020).The patient in this case describes chest pain, especially when eating so this disease could have been an option but it can be ruled out because there is no associated dysphagia.
Treatment Plan
Proton pump inhibitor (PPI) medications are the first line treatment for GERD. Lifestyle modifications are also recommended weight loss for overweight patients, avoiding late night meals, and avoiding easting foods such as foods with high fat, spicy, coffee, tea, tomatoes, and citrus (Katz et al., 2022)
The patient can be started at a low does PPI and reassessment should be done in 4 weeks to check if it is functioning. PPIs are related to symptom relief usually after 4 weeks in patients, (Katz et al., 2022) if not working by then, dose may be increased.
References
Clarrett DM, Hachem C. Gastroesophageal Reflux Disease (GERD). Mo Med. 2018 May-Jun;115(3):214-218. PMID: 30228725; PMCID: PMC6140167.
Gorti, H., Samo, S., Shahnavaz, N., & Qayed, E. (2020). Distal esophageal spasm: Update on diagnosis and management in the era of high-resolution manometry. World Journal of Clinical Cases, 8(6), 1026–1032. https://doi.org/10.12998/wjcc.v8.i6.1026
Narayanan M, Reddy KM, Marsicano E. Peptic Ulcer Disease and Helicobacter pylori infection. Mo Med. 2018 May-Jun;115(3):219-224. PMID: 30228726; PMCID: PMC6140150.
Taraszewska, A. (2021, January 29). Risk factors for gastroesophageal reflux disease symptoms related to lifestyle and Diet. Roczniki Panstwowego Zakladu Higieny. Retrieved July 19, 2022, from https://pubmed.ncbi.nlm.nih.gov/33882662/
2. [Rajwant Brar]
patient coming into the clinic with complaints of mid-epigastric pain at 46-year-old can be due to quite a few different diseases. The most probable cause is going to be Gastroesophageal Reflux Disease. GERD occurs after meals, with the contents of the stomach refluxing back into the esophagus. This can cause feelings of heartburn, chest pain, regurgitation, nausea, cough, and a sour taste in the mouth (Cash et al., 2020). This patient presenting with symptoms of mid-epigastric postprandially especially after intaking large meals of fast food, which intensify at night. With little to no relief after the usage of over-the-counter tums. And slight tenderness to the epigastric area. Many clinicians can diagnose GERD based in signs and symptoms presented by the patient and taking in a good history of present illness. But even though the probable cause is GERD it is important to rule out any cardiac issues. As cardiac illnesses can also present with gastrointestinal symptoms (Thygesen et al., 2018).
Treatment for this patient would be following the American College of Gastroenterology guidelines of prescribing the patient a proton pump inhibitor as it is considered the gold standard of treatment for patient with GERD. But the clinicians have to be cautious of long-term effects of PPI’s as it can cause C. Diff (Katz et al., 2021). After 8 weeks of PPI’s transition the patient into an H2 receptor. This patient I would start him on omeprazole 20mg once daily 30 minutes before meals. If the patient is not currently taking Plavix. Patient can continue over the counter antiacids for additional relief (Katz et al., 2021). Education is important in a dietary sense. The patient needs to avoid foods containing chocolate, excessive fat, caffeine, spices, and carbonated beverages which can exacerbate symptoms. If patient fails 2 treatments, a referral to gastroenterology is warranted. Patient is to come back to the clinic in 2 weeks for re-evaluation (Cash et al., 2020).
Other diagnoses for this patient can be Peptic Ulcer Disease. Peptic Ulcer Disease can also cause epigastric pain, and chest discomfort which is some of the symptoms the patient is experiencing. His symptoms are sometimes relieved by tums, but he is intaking about 10-12 of them a day. Peptic Ulcer Disease is often caused excesses acid and pepsin in the gastrointestinal tract. To treat peptic ulcer disease, we must be able to find the cause, sometimes it can be associated with bacteria called helicobacter pylori, or by the overuse of NSAIDS (Kamada et al., 2021). As the management will be tailored to the cause of the disease. With H. Pylori patient will take medication for about 14 days with antibiotics and proton pump inhibitors. And with NSAIDS patient needs to stop utilizing them. In addition to taking a PPI (Kamada et al., 2021).
As mentioned before, gastrointestinal symptoms can present in cardiac disease such as an acute myocardial infraction. And it is important to rule it out. When a patient is suffering from an acute MI they may complain of chest pain, nausea, vomiting, indigestion, and appear to be diaphoretic (Thygesen et al., 2018). The indigestion, nausea, vomiting and chest pain can also present in gastrointestinal issues. And if an accurate H&P is not obtained there are important items that can be missed. In accordance with the American Cardiology College and American Heart Association the diagnoses of an acute MI should be managed within the first 120 minutes from diagnoses to catheterization (Gulati et al., 2021). If a patient present in a primary care setting with complains of chest pain and an MI is suspected they would order an EKG, if positive indication of an MI an initiation to transfer to a local cardiac receiving ER would be in process (Gulati et al., 2021). While administering aspiring 324 mg chewable. Nitroglycerin 0.3 mg sublingual every 5 minutes for a total of 3 doses if the patient is not hypotensive. While initiating oxygen at 2L-4L via nasal canula. After hospital discharge, it’s important to start the patient on a high intensity statin. And education on lifestyle modifications such as diet and exercise (Gulati et al., 2021).
References
Cash, J. C., Glass, C. A., & Mullen, J. (2020). Family Practice Guidelines (5th ed.). Springer Publishing Company.
Gulati, M., Levy, P. D., Mukherjee, D., Amsterdam, E., et al. (2021). 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, Volume 144 (22) e368–e454. https://doi.org/10.1161/CIR.0000000000001030
Kamada, T., Satoh, K., Itoh, T., Ito, M., et al. (2021). Evidence-based clinical practice guidelines for peptic ulcer disease 2020. Journal of Gastroenterology, 56(4), 303–322. https://doi.org/10.1007/s00535-021-01769-0
Katz, P. O., Dunbar, K. B., Schnoll-Sussman, F. H., Greer, K. B., et al. (2021). Acg clinical guideline for the diagnosis and management of gastroesophageal reflux disease. American Journal of Gastroenterology, 117(1), 27–56. https://doi.org/10.14309/ajg.0000000000001538
Thygesen, K., Alpert, J. S., Jaffe, A. S., Chaitman, B. R., et al. (2018). Fourth universal definition of myocardial infarction (2018). Circulation, 138(20). e618–e651 https://doi.org/10.1161/cir.0000000000000617
