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Case Study #38: Daniel Shemoore


Med Surg Case Study

Daniel Shemoore | 55 years old


Chief Complaint: Daniel Shemoore presents to the gastroenterology clinic with complaints of chronic heartburn and difficulty swallowing, which has worsened over the past several months.


Medical History:

Daniel has a history of gastroesophageal reflux disease (GERD) for the past 10 years. He has been managing it with over-the-counter antacids and occasional proton pump inhibitors (PPIs). He reports frequent episodes of heartburn, especially after meals, and notes that he often wakes up at night with a burning sensation in his chest. Daniel has no history of smoking or alcohol use.


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Nurse's Note:

  • Patient reports that his heartburn has become more frequent and severe, and he now experiences difficulty swallowing solid foods. Daniel describes the sensation as food "getting stuck" in his chest. He denies any weight loss, vomiting, or bleeding.


Vital Signs:

  • Blood pressure: 128/76 mmHg

  • Heart rate: 82 bpm

  • Respiratory rate: 16 breaths/min

  • Temperature: 98.7°F (37.1°C)

  • SpO2: 99% on room air


Provider's Orders:

  • Prepare the patient for EGD and biopsy.

  • NPO (nothing by mouth) after midnight before the procedure.

  • Administer IV fluids: Normal Saline at 75 mL/hr pre-procedure.

  • Continue current PPI: Omeprazole 40 mg PO daily.

  • Provide education on post-procedure care and dietary modifications.

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Follow Up Questions:


Question 1: What is the significance of the EGD findings in Daniel’s case?


Question 2: Why is Daniel prescribed a PPI, and what is its role in managing his condition?


Question 3: What lifestyle modifications should Daniel implement to manage his GERD and Barrett Esophagus?


Question 4: What are the potential complications if Barrett Esophagus is left untreated or poorly managed?




Answers to Questions Below




Answers


Answers


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