GERD

If you can not do it please don’t accept

Mrs. B is a 55-year-old, white, female

Source: Self, reliable source

Subjective:

Chief complaint: “I have acid reflux.”   

HPI:  Patient states she has been having burning in her chest over the past 2-3 weeks. It is worse with consumption of spicy foods, alcohol and caffeinated beverages. She denies any nausea, vomiting, abdominal pain, blood in stools, food getting caught in throat or painful swallowing. She denies any chills or fever. She states she has been more stressed at work, which seemed to coincide with the onset of her symptoms. She has been taking Tums, which helps “a little.”

Allergies: NKA

Current Mediations:

Ferrous sulfate, 325 mg, daily

Clopidogrel, 75 mg, daily

Aspirin, 81 mg, daily

Ramipril, 5 mg, daily

Rosuvastatin, 20 mg, daily

Oxybutynin, 3.9 mg/24 patch

Fluoxetine, 10 mg, daily

Ibandronate, 150 mg, monthly

Tums, PRN                                                                                                                

Pertinent History: Iron deficiency anemia, STEMI (two months ago), hypertension, hyperlipidemia, urge incontinence, depression, osteoporosis

Health Maintenance. Immunizations: Immunizations and pertinent screening up-to-date

Family History:

            Father – Myocardial infarction (deceased age 52)

            Mother – Atrial fibrillation (deceased age 79)

Social History: Patient lives with her husband. She smokes 1ppd (40 pack year history). She drinks a glass of wine each evening with dinner. She denies drug use.

ROS: Incorporated into HPI

Objective:

VS – BP: 145/92, HR: 86, RR: 16, Temp 97.6, oxygenation 96%, weight: 240 lbs, height: 54 inches.

Mrs. B is alert, awake, oriented x 3.  Patient is clean and dressed appropriate for age.

ENT: The tympanic membranes are pearly gray. The nasal mucosa is pink with no discharge. The oropharynx is pink with no tonsillar erythema or exudate. There is no evidence of abnormal masses or leukoplakia. No cervical lymphadenopathy

Cardiac: No cardiomegaly or thrills; regular rate and rhythm, no murmur or gallop. No peripheral edema or jugular vein distention

Respiratory: Clear to auscultation, but decreased breath sounds

Abdomen: Bowel sounds positive. Soft, nontender, nondistended, no hepatomegaly      

ECG: Sinus rhythm

CBC: Hematocrit and hemoglobin within normal range

H pylori breath test: Negative    

Assessment:

Diagnosis: Gastro-esophageal reflux, ICD-10: K21.9

Please answer the following:

1. What is your prescribed treatment plan (include specific dosage, frequency)? Why did you choose this treatment plan? In your answer, please describe, briefly, the pharmacodynamics (1 point) and pharmacokinetics (1 point) of your treatment choice and how they influenced your choice. Please describe how the patient comorbidities influenced your choice as well (1 point).  Are there any medical interactions to your choice (1 point)? 
2. Document the education you would provide for this patient, specific to the prescribed medication. Please include information pertinent to the patient (2 points) and common potential adverse effects (2 points).

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