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

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

HEENT

-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?

Clinical Course The patient underwent upper endoscopy, which revealed multiple, circular, confluent erosions of the distal esophagus. There was no evidence of bleeding, ulcerations, stricture, or esophageal metaplasia. The patient was treated with an 8-week course of 30 mg/day lansoprazole and both heartburn and dysphagia resolved. Approximately 10 weeks after PPI therapy was discontinued, the patient reported that his reflux symptoms had returned and that he was again suffering from frequent post-prandial and nocturnal episodes of reflux. Patient Case Question 8. What therapeutic options are now available for this patient? Patient Case Question 9. Based on upper endoscopy test results, what grade of esophagitis can be assigned to this patient’s condition?

Bruyere, Harold J.. 100 Case Studies in Pathophysiology (Kindle Locations 2538-2542). Wolters Kluwer Health. Kindle Edition.

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