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
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
Citrus fruits and juices (upset stomach) Dogs (itchy eyes, runny nose, sneezing) Erythromycin (unknown symptoms)
ROS (−) H/A, dizziness, recent visual changes, tinnitus, vertigo (−) SOB, wheezing, cough, PND (+) frequent episodes of burning, non-radiating substernal CP (+) dysphagia (−) sore throat or hoarseness (−) N/V, diarrhea, BRBPR or dark/tarry stools (−) recent weight change PE and Lab Tests Gen The patient is a pleasant, talkative Native American man who is wearing a sports jacket, jeans, and tennis shoes. He looks his stated age and does not appear to be in distress.
VS See Patient Case Table 25.1
Skin No rashes or lesions noted
-PERRLA EOMI (−) arteriolar narrowing and A-V nicking Pink, moist mucous membranes (−) tonsils Oropharynx clear
Lungs CTA Heart
Regular rhythm (−) additional heart sounds
Abd Normoactive BS
Soft, NT/ND (−) HSM (−) bruits
Genit/Rec (−) hemorrhoids (−) rectal masses Brown stool without occult blood Prostate WNL
Ext (−) CCE
Neuro A & O for person, time, place CNs II–XII intact Strength 5/5 upper/lower extremities bilaterally
Patient Case Question 1. Which clinical information suggests worsening symptoms of GERD in this patient? Patient Case Question 2. Which symptom(s) indicates the possible severity of the patient’s GERD? Patient Case Question 3. Are the patient’s symptoms classic or atypical? Patient Case Question 4. Identify all those factors that may be contributing to the patient’s symptoms. Patient Case Question 5. Why is the drug verapamil a potential contributing factor to the patient’s symptoms? Patient Case Question 6. What non-pharmacologic therapies or lifestyle modifications might be beneficial in the management of this patient’s acid reflux disease? Patient Case Question 7. What pharmacotherapeutic alternatives are available for the treatment of this patient’s GERD?