Scribd Logo
Upload

Welcome to Scribd!

  • 102 views

    Case Scenario 3 Gerd

    Uploaded by

    Princess Faniega Sugaton
    1. The patient has been experiencing symptoms of GERD for 1 month including heartburn, chest pain, cough, and regurgitation. 2. She has a history of eating large, late night meals containing fried and fatty foods with little vegetable intake. 3. She presented with difficulty swallowing, heartburn, and blood-streaked vomitus after eating spicy food late at night. Initial examinations found her to be anxious, with facial grimacing and difficulty swallowing.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Case Scenario 3 Gerd

    Uploaded by

    Princess Faniega Sugaton
    102 views4 pages
    1. The patient has been experiencing symptoms of GERD for 1 month including heartburn, chest pain, cough, and regurgitation. 2. She has a history of eating large, late night meals containing fried and fatty foods with little vegetable intake. 3. She presented with difficulty swallowing, heartburn, and blood-streaked vomitus after eating spicy food late at night. Initial examinations found her to be anxious, with facial grimacing and difficulty swallowing.

    Original Description:

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    1. The patient has been experiencing symptoms of GERD for 1 month including heartburn, chest pain, cough, and regurgitation. 2. She has a history of eating large, late night meals containing fried and fatty foods with little vegetable intake. 3. She presented with difficulty swallowing, heartburn, and blood-streaked vomitus after eating spicy food late at night. Initial examinations found her to be anxious, with facial grimacing and difficulty swallowing.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    102 views4 pages

    Case Scenario 3 Gerd

    Uploaded by

    Princess Faniega Sugaton
    1. The patient has been experiencing symptoms of GERD for 1 month including heartburn, chest pain, cough, and regurgitation. 2. She has a history of eating large, late night meals containing fried and fatty foods with little vegetable intake. 3. She presented with difficulty swallowing, heartburn, and blood-streaked vomitus after eating spicy food late at night. Initial examinations found her to be anxious, with facial grimacing and difficulty swallowing.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 4

    CASE SCENARIO 3: GASTROESOPHAGEAL REFLUX DISEASE (GERD)

    HEALTH HISTORY

    Patient has suffered 1 month history of episodes of mid epigastric pain, burning sensation in
    his chest, an association dry cough, and occasional regurgitation. The pain worsens after
    eating and when he is lying flat. The patient has increasing postprandial fullness and early
    satiety. He also sates waking up from the pain and burning with a sore throat and hoarse
    voice. The patient reports associated mid-thoracic, bilateral back pain that occurs during the
    episodes. The symptoms are partially relieved by adjusting from a lying to a sitting position
    and with the use of over-the-counter medications (Zantac).

    SOCIAL HISTORY

    Patient DKD, 53 years old, a registered nurse in profession and working as a full time ICU
    nurse in Cadiz District Hospital. She is happily married with 2 dependents. Her husband is
    also working as a Bank Teller. She loves what she’s doing especially taking care of her
    critically ill patients. She stated that due to her work there are times that she can skip her
    meals. She tends to eat larger meals and she is also eating late at night. She loves to eat pork
    and beef. She is fond in eating dishes that are fried and fatty in preparation. She seldom eats
    vegetables. She doesn’t smoke but exposed to second hand smoking because of her
    husband addiction to cigarette.

    HISTORY OF PRESENT ILLNESS

    24 hours prior to admission patient suffer pyrosis after binged eating late at night. She ate
    spicy chicharon She took Zantac that gave her immediate relief of her symptoms. After 2
    hours she woke up due to indigestion episodes and regurgitation and presented difficulty in
    swallowing.
    Upon admission patient seems to be agitated and anxious about her new onset of symptoms.
    Her baseline vital signs are BP: 140/90 mmhg PR: 96bpm RR: 22cpm Temp: 36.8 O2sat: 99%
    Pain scale of 7 out of 10. Patient is overweight, facial grimacing and has a guarding behavior.
    Upon physical examination, throat appears to be moist and pinkish with no nodular lesions
    and with normal size of thyroid. Lungs are clear upon auscultation and no adventitious
    breath sounds noted. Abdomen is non distended, soft and non-tender. Muscle strength of
    5/5 in both upper and lower extremities.

    1. Patient’s Information
    Name: DAWN KRISTINE DIAZ
    Address: VICTORIAS CITY
    Age: 54 YO
    Sex: FEMALE
    Civil Status: MARRIED
    Date of birth: DECEMBER 22, 1968
    Educational Attainment: COLLEGE GRADTUATE
    Occupation: NURSE
    Religion: ROMAN CATHOLIC

    2. Other Information
    No. of dependents :2
    Date of admission : January 24, 2023, 4:45 am
    Chief complaints : difficulty swallowing, heartburn after eating,
    blood-streaked vomitus
    Weight : 89 KGS
    Height : 5’6
    Admitting diagnosis : GERD, T/C PERFORATED PUD
    Allergies : NONE
    Attending Physician : DR. CARLA MAE GARCIA

    3. Initial Assessment and findings:


    1. Weight: 89 kgs
    2. Anxious
    3. (+) facial grimace
    4. (+) difficulty swallowing
    5. (+) chest pain

    4. Doctor’s Order

    DATE DOCTOR’S ORDER


    January 24, 2023 Pls admit under the service of Surgery
    4:45 am TPR q4h
    MIO q shift
    BP: 130/80
    Diet: DAT with aspiration precaution
    HR: 105 bpm (low sodium, low fat, no caffeine diet)
    RR: 23 cpm Labs: CBC,Platelet
    T: 36.8 C RBS
    O2 sat: 98% Serum Na, K, Cl
    Wt: 89 kgs ESR, CRP
    Urinalysis
    Diagnostic tests: Chest Xray PA
    For Gastroesophageal Reflux scan
    Barium Swallow
    IVF: PNSS 1L x 80 cc/hr x 2 bottles

    Medications:
    Risec 40mg IVTT now
    Risec 80mg + 100ml PNSS q8h via IV infusion
    Calci-Aid 500mg 1 cap TID p.o.
    Prelax 5mg 2 tabs ODHS p.o. x 2 days
    Plazimide 10mg IVTT q8H PRN for nausea and vomiting
    Siverol 50mg IVTT q6h PRN for breakthrough pain
    S/O:
    > Secure consent for gastroesophageal reflux scan
    > Place patient in semi-fowlers position
    > Monitor for bloody stools/vomitus
    > Refer accordingly

    Dr. C.M. Garcia


    Lic. No. 012293
    5. Laboratory & Diagnostic Findings

    COMPLETE BLOOD COUNT


    Test Requested Result Normal Values
    Hemoglobin 130 120-170 g/L
    Hematocrit 0.41 0.40-0.54
    RBC Count 4.9 4.00-5.50x10^12/L
    WBC Count 6.50 5.00-10.00x10^9/L
    Differential Count
    Neutrophil 0.66 0.50-0.70
    Lymphocyte 0.30 0.20-0.40
    Eosinophyl 0.03 0.00-0.05
    Monocytes 0.01 0.00-0.09
    Basophil 0.00 0.00-0.01
    Platelet 250 150.00-400.00x10^9/L

    Clinical Chemistry
    S.I. Unit Conventional
    Test
    Result Normal Value Result Normal Value
    Glucose (RBS) 110 80-130 mg/dL
    Sodium 145.00 135-148 mmol/L
    Potassium 5.0 3.5-5.0 mmol/L
    Chloride 105.00 98-107mmol/L
    ESR 29 0-29 mm/hr
    CRP 9 <10 mg/L

    URINALYSIS
    Physical Chemical
    Color Dark Straw Albumin Negative
    Reaction pH 6.0 Sugar Negative
    Transparency Hazy Ketones Negative
    Specific Gravity 1.022 Bilirubin Negative
    Microscopic Cells Leukocytes Negative
    Pus Cells 3-5/HPF Blood Negative
    RBC 0-3/HPF Nitrite Negative
    Yeast Cells - Urobilinogen Negative
    Bacteria -
    Investigations

    Chest Xray PA result:

    Essentially normal lung fields

    Barium Swallow Interpretation:

    Enlarged veins and varices

    Gastroesophageal Reflex Scan Interpretation:

    Reflux is 10% at any pressure level

    *Normal values: reflux is less than or equal 4% across the esophageal sphincter

    You might also like