Listen to

your Gut
Bimbao, Elijah Blaise
Figueroa, Louie Donnard
Villanueva, Justine

GENERAL DATA

R.A.
58/Male
Married
Filipino
Brgy. Zone 3, Cadiz City,
Negros Island Region

CHIEF COMPLAINT

Epigastric pain

ISTORY OF PRESENT ILLNESS

NO MEDS
TAKEN.
NO
CONSULT

2
weeks
PTC

With
associate
d

UNDOCUMENTE
D

STORY OF PRESENT ILLNESS

3 days
PTC
Took

CONSU
LT

PAST MEDICAL HISTORY

(-)
(-)
(-)
(-)
(-)

Hypertension
Diabetes Mellitus
Bronchial Asthma
Pulmonary Tuberculosis
Food and Drug Allergy

FAMILY HISTORY

(+) Hypertension Maternal

side
(+) Stroke Maternal side
(-) Diabetes Mellitus
(-) Bronchial Asthma
(-) Heart Disease

ERSONAL AND SOCIAL HISTORY

Previous smoker: 8 pack years

Non-Alcoholic beverage drinker
No illicit drug use
No history of herbal medicine use
Usual diet: steamed rice, fish,
vegetables and fond of drinking
coffee
Government employee

REVIEW OF SYSTEMS

General: (-) fatigue, (-) body malaise

Skin: good skin turgor, (-) Dry skin, (-) jaundice, (-) diaphoresis
Head: (+) Dizziness
Eyes: (-) Sunken Eyeball, (-) blurring of vision
Ear: (-) Vertigo, (-) decreased hearing
Nose and Sinuses: (-) discharges
Mouth and Throat: (-) Dry mouth, (-) bleeding
Neck: (-) stiffness
Respiratory: (-) Dyspnea
Cardiac: (-) cyanosis, (+) palpitations
GI: (-) diarrhea, (-) hematemesis, (-) hemoptysis, (-) melena, (-)
hematochezia
Urinary: (-) Decreased urine output, (-) dysuria
PVS: (-) edema
Musculoskeletal: (-) muscle pain, (-) joint pain
Neurologic: (-) headache, (-) seizures
Psychiatric: (-) nervousness

PHYSICAL EXAMINATION
Vital signs:
BP: 110/70 mmHg
HR: 67 bpm
RR: 18 cpm
Temp: 36C
Weight: 67.8 kg.
Height: 160 cms.
BMI: 26.4

PHYSICAL EXAMINATION
GENERAL SURVERY:
Patient is conscious, coherent and not in
cardiopulmonary distress

SKIN:
Good turgor
(-) pallor, no jaundice or cyanosis
No rashes

PHYSICAL EXAMINATION
HEAD
Normocephalic
Hair is black and evenly distributed
No masses or lesions noted
EYES
Anicteric sclera, Pink palpebral conjunctiva
No redness or discharges
EARS
No swelling or deformities
No bleeding or secretions

PHYSICAL EXAMINATION
NOSE
Mucosa is pink
Septum is found midline
No tenderness of frontal, maxillary sinuses
No discharges or bleeding
MOUTH & THROAT
Pink oral mucosa
No tonsillar enlargement
No gum bleeding

PHYSICAL
Physical EXAMINATION
Examination
NECK
No neck vein engorgement, no cervical
lymphadenopathy
Thyroid gland not enlarged, non-tender, no
masses

RESPIRATORY
Symmetric chest expansion
Normal tactile fremitus
Resonance over all lung fields
Crackles on right basal area, clear breath
sounds on left lung

PHYSICAL
Physical EXAMINATION
Examination
CARDIOVASCULAR
Adynamic precordium
PMI at 5th ICS Left MCL
Regular rhythm, Distinct S1 & S2
No murmurs

GASTROINTESTINAL
Slightly protuberant abdomen, No striations, ascites
Normoactive bowel sounds of 8/min at RLQ, (-) bruits
Tympanic and dull sounds equally heard on all
quadrants
(+) tenderness on the epigastric area
No hepatosplenomegaly, no masses
(-) Murphys sign

PHYSICAL
Physical EXAMINATION
Examination
GENITOURINARY:
(-) Hypogastric distention, (-) tenderness
No costovertebral tenderness

PERIPHERAL VASCULAR
Grossly normal extremities, no edema
Extremities cool to touch
Peripheral pulses 2+, regular
CRT <2 seconds

PHYSICAL
Physical EXAMINATION
Examination
MUSCULOSKELETAL
(-) Muscle atrophy
Normal active and passive ROM on both upper and lower
extremities

NERVOUS
MSE: Conscious, coherent, oriented to person, place and time,
intact immediate, remote & recent memory, no disturbances in
thought process, content or perception
CRANIAL NERVES

I-XII: Unremarkable
MOTOR
- Muscle strength 5/5 all extremities
SENSORY
- Intact sensation to light touch at all levels

PHYSICAL
Physical EXAMINATION
Examination
Reflexes
- Normoactive DTRs of 2+ at all
extremities
- No Babinski

Meningeal
- No nuchal rigidity

Cerebellar
No nystagmus, dysarthria, ataxia, or

dysdiadochokinesia

SALIENT
FEATURES
Salient
Features

2 weeks cough with yellowish

phlegm
Undocumented intermittent
fever
Epigastric pain
(+) crackles on right basal
area

Differential Diagnosis
Diagnosis

Rule In

Rule Out

CAP-LR

(+) crackles on right

basal area
(+) 2 weeks history
of cough with
yellowish sputum
(+) undocumented
fever
stable vital signs

GERD

(+) epigastric pain

Pulmonary
Tuberculosis

(+) 2 weeks history

of cough with
yellowish sputum
(+) undocumented
fever

(-) hemoptysis
(-) chills
(-) night sweats

Acute Coronary
Syndrome

(+) epigastric pain

(+) palpitation

(-) Chest pain

(-)

INITIAL IMPRESSION

Gastroesophageal Reflux
Disease r/o Acute
Coronary Syndrome,
Community Acquired
Pneumonia - Low Risk

PLANPLAN
Diagnostics:
12-Lead ECG
Chest X-ray PA view
Sputum AFB

ECG
ECG
RATE: 51 bpm
PR Int.: 0.16
sec
QRS: 0.04-0.08
sec
Axis: Normal
axis
Hypertrophy:
No Hypertrophy
Interpretation:
Sinus
Bradycardia

PLANPLAN
Therapeutics:
Omeprazole 40mg/tab, 1 tab once
a day 30 minutes before breakfast
for 14 days
Co-amoxiclav 1gm/tab, 1 tab two
times a day for 7 days
N-Acetycysteine 600mg/tab,
dissolve 1 tab to glass of water
and drink once a day before

PLANPLAN
Non-pharmacologic
Avoid soda or caffeinated
drinks
Increase oral fluid intake
Daily exercise
Advised follow up once with
laboratory results

CASE DISCUSSION

Anatomic radiographic landmarks of the lower esophageal sphincter

(LES).

Gastroesophageal Reflux
Disease (GERD)
Gastroesophageal reflux is a normal
physiologic phenomenon
experienced intermittently by most
people, particularly after a meal.
Gastroesophageal reflux disease
(GERD) occurs when the amount of
gastric juice that refluxes into the
esophagus exceeds the normal limit,
causing symptoms with or without
associated esophageal mucosal
E.J. Kiuipers, Best Practice & Research: Clinical Gastroenterology, 2nd ed
injury.

Physiologic vs Pathologic
Physiologic GERD

Postprandial
Short lived
Asymptomatic
No nocturnal
symptoms

Pathologic GERD
Symptoms
Mucosal injury
Nocturnal
symptoms

Harrison's Principles of Internal Medicine 19th ed

Epidemiology
occurs in all ages, most common in
patients older than 40.
No much difference in incidence between
men and women

Clinical Manisfestations
Most common symptoms

Heartburnretrosternal burning
discomfort
Regurgitationeffortless return of
gastric contents into the pharynx
without nausea, retching, or
abdominal contractions
Water brash- hypersalivation
Belching

Atypical symptoms:
coughing
chest pain
wheezing
pharyngitis
hoarseness
dental erosions

Harrison's Principles of Internal Medicine 19th ed

Extraesophageal manifestations of
GERD
Otolaryngeal:
hoarsness/laryngitis
Chronic sore throat

Other:
Noncardial chest pain

Harrison's Principles of Internal Medicine 19th ed

Alarm Signs or Symptoms

may be indicative
of complications of
GERD such as
Barrett's
esophagus,
esophageal
strictures or
esophageal cancer

dysphagia
early satiety
GI bleeding
odynophagia
vomiting
unexplained weight
loss
iron deficiency anemia
choking
continuous pain

Harrison's Principles of Internal Medicine 19th ed

Diagnostic Evaluation
If classic symptoms of heartburn and
regurgitation exist in the absence of
alarm symptoms the diagnosis of
GERD can be made clinically and
treatment can be initiated

Harrison's Principles of Internal Medicine 19th ed

Esophagogastrodudenoscop
y
Endoscopy (with biopsy if
needed)

In patients with alarm

signs/symptoms
Those who fail a medication
trial
Those who require long-term tx

Lacks sensitivity for

identifying pathologic reflux
Absence of endoscopic
features does not exclude a
GERD diagnosis
Allows for detection,
stratification, and
management of esophageal
manisfestations
E.J. Kiuipers, Best Practice or
& Research: Clinical Gastroenterology, 2nd ed
complications of GERD

pH
24-hour pH monitoring
Accepted standard for establishing or
excluding presence of GERD for those
patients who do not have mucosal
changes
Trans-nasal catheter or a wireless,
capsule shaped device

E.J. Kiuipers, Best Practice & Research: Clinical Gastroenterology, 2nd ed

 Hearburn and acid regurgitation- if

present an official diagnosis of GERD
can be made.
Upper endoscopy is not required to
make an initial diagnosis of GERD
because it is of little value.

Sollano et al., Clinical Practice Guidelines on the diagnosis and treatment of

gastroesophageal reflux disease (GERD), P3

GERD
GERD is a condition resulting
from the recurrent backflow of
gastric contents into the
esophagus and adjacent
structures causing troublesome
symptoms and/or tissue injury.

Lagergren J, Bergstrom R, Lindgren A, et al. Symptomatic gastroesophageal reflux as a risk factor for
esophageal adenocarcinoma. N Engl J Med 1999;340:825-31.

Pathophysiology
Three dominant mechanisms of esophagogastric
junction incompetence
1. transient LES relaxations (a vagovagal reflex
in which LES relaxation is elicited by gastric
distention),
2. LES hypotension
3. anatomic distortion of the esophagogastric
junction inclusive of hiatus hernia.
. Esophagitis occurs when refluxed gastric acid
and pepsin cause necrosis of the esophageal
mucosa causing erosions and ulcers
Harrison's Principles of Internal Medicine 19th ed. P. 1906

Management
Lifestyle modifications
1. avoidance of foods that reduce LES
pressure, making them refluxogenic (these
commonly include fatty foods, alcohol,
spearmint, peppermint, tomato-based foods,
and possibly coffee and tea);
2. avoidance of acidic foods that are inherently
irritating; and
3. adoption of behaviors to minimize reflux
and/or heartburn. (head elevation, heavy
meals)
Kaltenbach T, Crockett S, Gerson LB. Are lifestyle measures effective in patients with gastroesophageal reflux disease? An evidence-based
approach. Arch Intern Med 2006;166:965-71.

Management
Weight reduction
Weight reduction and elevation of head
of the bed may contribute to symptom
improvement. (Recommendation 8)
A BMI >25 was a significant risk factor for
GERD in an Asian study
In a recent prospective interventional trial
involving 332 adults, a structured weight loss
program led to complete resolution of GERD
symptoms in 65% of subjects and reduction
of GERD symptom scores in 81%.
Rosaida MS, Goh KL. Gastro-oesophageal reflux disease, reflux oesophagitis
and non-erosive reflux disease in a multiracial Asian population: a prospective,
endoscopy based study. Eur J Gastroenterol Hepatol 2004;16:495-501.

Singh M, Lee J, Gupta N, et al. Weight loss can lead to

resolution of gastroesophageal reflux disease symptoms: a
prospective intervention trial. Obesity (Silver Spring)
2013;21:284-90.

Management
Proton pump inhibitors (PPIs)
Standard dose PPI once daily for eight
weeks, taken 30 minutes before
morning meal, is the cornerstone of
therapy for erosive esophagitis.
(Recommendation #7)
traditional delayed-release PPIs are
recommended to be administered 3060
minutes before meals to assure maximal
efficacy.
If eight weeks of standard once daily
Chiba N, De Gara
CJ, Wilkinson
JM, et al. Speed of healing
and
PPI
treatment
achieved
only a partial
Hershcovici T, Jha LK, Fass R. Dexlansoprazole MR: a
symptom relief in grade II to IV gastroesophageal reflux disease: a
Ann Med 2011;43:366-74.
meta-analysis. Gastroenterology
1997;112:1798-810.
relief of
symptoms, review.
administer
the same

Management
Proton pump inhibitors (PPIs)
If eight weeks of standard once daily
PPI treatment achieved only a
partial relief of symptoms,
administer the same PPI twice daily
or switch to a different PPI.
Several randomized trials showed better
improvement of symptoms by increasing
the PPI dose to twice daily or by shifting
to
a different
dose PPI.
Fass R, Murthy
U, Hayden
CW, et al. Omeprazole 40 standard
mg once a day is
equally effective as lansoprazole 30 mg twice a day in symptom control of
patients with gastro-oesophageal reflux disease (GERD) who are resistant to
conventional-dose lansoprazole therapy-a prospective, randomized,
multi-centre study. Aliment Pharmacol Ther 2000;14:1595-

Fass R, Sontag SJ, Traxler B, et al. Treatment of patients with

persistent heartburn symptoms: a double-blind, randomized
trial. Clin Gastroenterol Hepatol 2006;4:50-6.

Management
Histamine2 receptor antagonists
(H2RAs)
Intermittent H2-receptor
blockers may be given as
alternative to patients
intolerant to PPIs.
(Recommendation #11)
H2RAs may be used as
maintenance therapy for PPIintolerant patients,86 but because

Donnellan C, Sharma N, Preston C, et al. Medical treatments for the maintenance therapy of reflux oesophagitis and endoscopic negative
reflux disease. Cochrane Database Syst Rev 2005:CD003245.

Management
Laparoscopic Nissen fundoplication - proximal
stomach is wrapped around the distal esophagus
to create an antireflux barrier
laparoscopic fundoplication done in highvolume, expert centers, is an option only
among patients with GERD whose
symptoms respond to PPI therapy but not
amenable to long-term medical treatment.
(Recommendation #25)
A Cochrane review of four RCTs involving 1,232
patients showed significant improvements in
symptoms of heartburn,Oelschlager
reflux
and bloating.
BK, Quiroga E, Parra JD, et al. Long-term outcomes after
Wileman SM, McCann S, Grant AM, et al. Medical versus surgical
management for gastro-oesophageal reflux disease (GORD) in adults.
Cochrane Database Syst Rev 2010:CD003243.

laparoscopic antireflux surgery. Am J Gastroenterol 2008;103:280-7;

quiz 288.

FAMILY
ASSESSMEN
T

GENOGRAM

FAMILY MAP

ROM
EO

MAR
K
Legend:
Dysfunctional
Functional
=
Over-involved =
Coalition
=
Clear boundaries
=
Rigid boundaries
=
Diffused boundaries

VICT
ORIA

RICK
Y

PET
ER

ECOMAP

Friend
s
Healt
h
Cente
r

Churc
h

5k

m
Aligum
Family

km

Hospit
al

70
km
VICTORI
A

ROMEO

km
MARK

RICKY

km

PETER

Neighbo
rs
Positive relationship =
Very Strong relationship =
Strained relationship =
Negative relationship =

Relativ
es

FAMILY
WELLNESS
PLAN

Name

Age/S
ex

Composit
ion

ROMEO

58/M

Father

Well

Annual periodic physical

examination
Daily BP monitoring
Low salt, low fat diet
Increase oral fluid intake,
avoid caffeinated drinks
Exercise for 3-4 times per
week, 30 minutes per day

Mother

Well

Monthly self breast

examination and annual
check-up to MD
Daily BP monitoring
Low salt, low fat diet; high
fiber diet
Pre-menopausal counseling
Exercise for 3-4 times per
week, 30 minutes per day

VICTORI 57/F
A

Statu
s

Plan

Name Age/
Sex

Composi
tion

MARK

27/M

Eldest

Well

RICKY

25/M

Middle
child

Well

Last child

Well

PETER 23/M

Statu
s

Plan
Annual periodic physical examination
BP monitoring every month
Family, marital counseling
Immunization of Pneumococcal vaccine
Reduce alcohol intake to once per week,
smoking cessation
Exercise for 3-4 times per week, 30
minutes per day
High fiber diet
Annual periodic physical examination
BP monitoring every month
Immunization of Pneumococcal vaccine
Reduce alcohol intake to once per week,
smoking cessation
Exercise for 3-4 times per week, 30
minutes per day
High fiber diet
Annual periodic physical examination
BP monitoring every month
Immunization of Pneumococcal vaccine
Reduce alcohol intake to once per week
Exercise for 3-4 times per week, 30
minutes per day
High fiber diet

APGAR
SCORE

APGAR

Almost
Always
(2)

Adaptation

I am satisfied that I can

turn to my family for
help when something is
troubling me.

Partnership

I am satisfied with the

way my family talks on
things with me and
shares problems with
me.

Growth

I am satisfied that my
family accepts and
supports my wishes to
take on new activities or
directions.

Affection

I am satisfied with the

way my family
expresses affection and
responds to my emotion
such as anger, sorrow
and love.

Some of
the time
(1)

Hardly
ever (0)

THANK YOU FOR

LISTENING.