Case Study & Discussion Questions

Mr. Brown, a 50 year-old male who comes into your office today complaining of  a constant burning pain in his stomach a couple of hours after he eats. He states that he was seen in the emergency room 2 days ago for the same complaint and was given something called a “GI cocktail” which relieved his symptoms. Mr. Brown reports that he enjoys coffee every morning with breakfast and sometimes in the afternoon with a donut.  A review of his records show that acute coronary syndrome was ruled out in the emergency room 2 days ago. His last stress test was 6 months ago, which was negative. EKG in the office today is normal.

Past Medical History: Obesity and High Cholesterol.

Surgical History: None.

Family history: Unknown he is adopted

Social History: Smoker x 10 years 1ppd, drinks 2-4 beers a day and ½ pack on the weekends. Denies recreational drugs, does not exercise.

Drug allergies: NKDA

Current medications: None

All vaccines are up to date. 

Vitals Height 69 inches, weight 205 pounds, BP 120/75, P 70, R 16.

Mr. Brown’s physical exam is normal, including the abdominal exam.

• What are your treatment goals for Mr. Brown today?
• What is your pharmacological plan and rationale? (cite with appropriate clinical practice guidelines or scholarly peer-reviewed articles and always include medication name, strength, dosage form, route, frequency and duration when making recommendations)
• Pick one medication from your response above and list 5 patient-centered teaching points for the medication.

Solution:

I would diagnose Mr. Brown with GERD. Since Mr. Brown has been tested negative for cardiac abnormalities, I would then deduct that his postprandial discomfort and acid reflux result from reflux of chyme from his stomach to his esophagus. His resting tone of his lower esophageal sphincter is lower than normal, permitting transient relaxation 1-2 hours postprandial….Please click the icon below to purchase full solution at $5