Chronic Health: Comprehensive Case Study
Part A

Setting: Skilled nursing facility. The facility largely offers residential care for senior citizens – mostly from the age of 65 and above.

The patient is a 72-year-old Caucasian male who has been undergoing rehabilitation treatment, specifically orthopedic physical therapy, deemed necessary from a medical point of view.

Clinical information:

Chief complaint: Client complains of abdominal pain and “heartburn.”

HPI: Patient points out that he has been experiencing serious pain (described as burning) in his abdomen for the last 2 days. Pain originates from the midepigastric area. At its worst, the patient gives an 8/10 rating to the pain. The patient points out that he has been having similar pain – which comes and goes - over the last 3 weeks. Discomfort mainly experienced in night-time and after ingesting spicy foods. The patient denies vomiting, and also denies having suffered any kind of trauma in the recent past. The patient is not on any over-the-counter medications at present.

PMH: No known allergies. Was diagnosed with Type II diabetes at age 51. Denies any depression. Denies HTN.

PSH: Cholecystectomy

FH: Has been married for 36 years and has 3 children – 2 boys, 1 girl. Father – deceased (at 87 -HTN). Mother – deceased (at 70 - breast cancer). Patient is the eldest of four siblings who are all alive.

ROS: GENERAL: Denies fatigue, night sweats, malaise, as well as chills. Patient has not experienced any unexplained weight loss in the recent past. HEENT: Denies headaches or ear ringing. Denies cataracts or double vision. Denies sneezing, sinus pressure, or congestion in the nasal cavity. Denies difficulty in swallowing or sore throat. Patient has not experienced any unexplained variation in his sense of smell. SKIN: No skin abnormalities identified. CARDIOVASCULAR: Denies any palpations or chest pain. RESPIRATORY: No hemoptysis. No cough or wheezing. GASTROINTESTINAL: Denies diarrhea. Denies flatulence. Denies vomiting. Reports abdominal pain. GENITOURINARY: Denies any penile discharge. Denies hematuria and dysuria. MUSCULOSCELETAL: Reports joint pain. PSYCHIATRIC: No diagnosed mental condition. NEUROLOGICAL: Denies dizziness, loss of sensation, or memory loss. ENDOCRINE: Has history of diabetes.

PE: VITAL SIGNS: Patient BMI = 26.8; T = 97.9F; BP = 120/75 mm Hg; R = 16/min; HR = 80/min. GENERAL: The patients is, from a general perspective, well groomed. He also appears alert and oriented. NECK: supple, no JVD or bruit. LUNGS/CHEST: expansion symmetric. No adventitious sounds. HEART/PERIPHERAL VASCULAR: No murmurs. Regular rate as well as rhythm. ABDOMEN: non-distended and non-tender. Active and normal bowel sounds. MUSCULOSKELETAL: Spine straight. Negative paresthesia.

Diagnostic Testing: Upper endoscopy: esophagitis. Ambulatory 24-hour PH monitoring.

Medical Decision Making: The diagnosis was in this case made on the basis of not only the presenting symptoms and physical examination, but also upon confirmation from the relevant tests.

Diagnosis/Clinical Impression: Gastroesophageal reflux disease (GERD). Differential Diagnosis: Acute gastritis

Plan/Interventions: A stepwise approach will be embraced with the overall objectives being prevention of recurrent esophagitis, ensuring that the esophagitis heals, and controlling the symptoms presently exhibited.

Given that the symptoms that the patient presents with are in this case moderate, it would be prudent to start him off with first-line agents. It is also important to note that on the basis of the fact that multiple folds appeared to be affected by multiple erosions, the patient has grade II esophagitis. Towards this end, H2 blocker therapy will be started. This will also come in handy given that the patient has reported that discomfort is mostly experienced in night time (i.e. nocturnal acid breakthrough). Considerations on this front could be inclusive of cimetidine (Tagamet), famotidine (Pepcid AC), and nizatidine (Axid).

Antacids will be given concomitantly. Antacids are effective in the neutralization of stomach acid. Considerations on this front could be inclusive of, but they are not limited to, Rolaids, Tums, and Mylanta.

Recommendations:

Famotidine 20mg. To be taken twice daily. To be taken for a maximum...…week).

Part B (Evidence-Based Research on Interventions Selected)

From the onset, it is important to note that as Chait (2010) points out, GERD happens to be rather common among the elderly. As a matter of fact, as the author further points out, it is the most frequent gastrointestinal disorder in this particular population. According to Jeffrey and Timothy (2018), histamine (H2) blockers come in handy in not only the reduction of GERD symptoms, but also in the improvement of life quality. More specifically, in the words of the authors, GERD patients who are exposed to treatment with histamine (H2) blockers happen to be “16% to 23% more likely to have heartburn remission, 20% to 25% more likely to have pain-free days, and 28% to 69% more likely to have improvement in overall symptoms compared with patients treated with placebo” (15). The H2 receptor blocker was selected over PPIs on the basis of available research indicating that the latter could be more effective than the former in some instances (or as an add-on to PPI therapy) (Wang, et al., 2013). To a large extent, both proton pump inhibitors (PPIs) and H2 receptor blockers (also referred to as histamine H2-receptor antagonists) function by reducing as well as blocking stomach acid production. Although PPIs are deemed stronger in this role, H2 receptor blockers are particularly effective - especially in the evening. In the present scenario, the patient reports that discomfort is mainly experienced in night time. Further, it should also be noted that as Wang et al. (2013) observe, “refractory GERD, defined as reflux symptoms either completely or incompletely responsive to PPI therapy, has become an important issue in clinical practice” (p. 78). Towards this end, it could be deemed prudent to incorporate H2 receptor blockers into the treatment equation. However, it is also important to note that as Sandhu and Fass (2017) point out, alongside the appropriate medical therapy, the relevance of lifestyle modifications cannot also be overstated…