In today’s case study we have a 46 year old with mid chest pain worse with eating. The key to this case study is the “worse with eating” component. Our patient has been eating more lately with work, and states the pain is worse when laying down. This points towards acid reflux which is often worse while laying down. The acid will follow gravity and moving upwards and causing pain. There does not appear to be any signs pointing to cardiac nature here. No shortness of breathe or cardiovascular risk factors. Of course we would need to ask the appropriate question to rule out any cardiac pathology. The questions we could ask to rule out angina would be to ask about shortness of breathe, diaphoresis, pain with exertion, and cardiac history.
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If cardiac pathology is ruled out than this becomes an abdominal focused assessment. Our patients mid chest pain is in the middle upper gastric area and is likely caused by the increased eating and lack of GI motility. Our top differential diagnosis would be GERD. The treatment for GERD would be lifestyle, diet, and a proton pump inhibitor (Maret-Ouda et. al., 2020). Hopefully with smaller meals, and not eating before bed our patient can get improvement. I would also recommend smaller bland meals. I would recommend a short term drug therapy of protonix 20mg po daily and re-evaluate the patient in the next 4-6 weeks.
Some of the other pathologies on the differential would include esophagitis and gastritis. It an be difficulty to definitively diagnosis gastritis without an upper GI scope. Endoscopy techniques are improving and the types of lights used can aid in accurate diagnosis (Rugge, et. al., 2021). With an upper scope gastritis can be diagnosed when reddening or edema of the gastric mucosa is found (Rugge, 2021). Gastric atrophy and the presence of H. Pylori can be precursors of cancer (Rugge, 2021). Therefore GI scope and biopsy in complicated cases of prolonged nausea, vomiting and abdominal cases can be warranted.
Maret-Ouda, J., Markar, S. R., & Lagergren, J. (2020). Gastroesophageal reflux disease: a review. Jama, 324(24), 2536-2547.
Rugge, M., Savarino, E., Sbaraglia, M., Bricca, L., & Malfertheiner, P. (2021). Gastritis: The clinico-pathological spectrum. Digestive and Liver Disease, 53(10), 1237-1246.
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