Case Scenario 3 Gerd
Case Scenario 3 Gerd
Case Scenario 3 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.
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
4. Doctor’s Order
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
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
*Normal values: reflux is less than or equal 4% across the esophageal sphincter