Med Surg Case Study #38: Daniel Shemoore

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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Daniel underwent an EGD with biopsy earlier today. The procedure revealed an area of red, inflamed mucosa in the lower esophagus, consistent with Barrett Esophagus.Biopsies were taken for further evaluation.

Nurse's Note:

Daniel tolerated the procedure well, with no complications. He is currently resting in the recovery area and reports mild throat discomfort.

Vital Signs

• Blood pressure: 126/74 mmHg

• Heart rate: 78 bpm

• Respiratory rate: 18 breaths/min

• Temperature: 98.5°F (36.9°C)

• SpO2: 98% on room air

Provider's Orders:

• Monitor for signs of post-procedure bleeding or perforation.

• Resume clear liquids after recovery, advancing to a soft diet as tolerated.

• Schedule follow-up appointment in 1 week for biopsy results and further management plan.

• Continue PPI: Omeprazole 40 mg PO daily.

• Educate the patient on avoiding foods that trigger GERD symptoms and the importance of long-term follow-up.

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Nurses Note: Daniel is discharged with instructions to follow a soft diet for the next 24 hours. He was provided with educational materials on Barrett Esophagus, GERD management, and the importance of follow-up care. Daniel was advised to continue taking his PPI as prescribed and to monitor for any new or worsening symptoms, such as difficulty swallowing, chest pain, or gastrointestinal bleeding.

Vital Signs:

• Blood pressure: 122/72 mmHg

• Heart rate: 76 bpm

• Respiratory rate: 16 breaths/min

• Temperature: 98.4°F (36.9°C)

• SpO2: 99% on room air

Provider's Orders:

• Discharge with follow-up in 1 week for biopsy results.

• Continue current PPI: Omeprazole 40 mg PO daily.

• Avoid alcohol, caffeine, and spicy foods.

• Educate the patient on lifestyle modifications, including weight loss, elevating the head of the bed, and avoiding late-night meals.

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

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Answers

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

The EGD findings revealed red, inflamed mucosa in the lower esophagus, consistent with Barrett Esophagus. Barrett Esophagus is a condition where the normal squamous epithelium of the esophagus is replaced by columnar epithelium, which can increase the risk of developing esophageal adenocarcinoma. Early detection and monitoring are crucial.

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

Daniel is prescribed a PPI (Omeprazole) to reduce stomach acid production and control his GERD symptoms. PPIs are effective in reducing acid reflux, which can help prevent further damage to the esophageal lining and manage symptoms associated with Barrett Esophagus.

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

Lifestyle modifications are essential for managing GERD and reducing the risk of complications from Barrett's esophagus.

Daniel should:

• Maintain a healthy weight: Excess weight can increase pressure on the lower esophageal sphincter.

• Elevate the head of the bed: This helps to prevent acid reflux while sleeping.

• Avoid trigger foods: Identifying and avoiding foods that trigger heartburn is crucial. Common culprits include caffeine, alcohol, spicy foods, and fatty meals.

• Eat smaller, more frequent meals: Overeating can exacerbate GERD symptoms.

• Quit smoking: Smoking can worsen GERD and increase the risk of esophageal cancer.

  
  

These lifestyle changes can reduce the frequency and severity of acid reflux, potentially slowing the progression of Barrett Esophagus and improving symptoms.

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

If Barrett's esophagus is left untreated or poorly managed, the most serious complication is the development of esophageal adenocarcinoma. Other potential complications include:

• Strictures: Narrowing of the esophagus, making it difficult to swallow.

• Esophageal ulcers: Sores in the lining of the esophagus.

• Hemorrhage: Bleeding from the esophagus.

• Aspiration pneumonia: Inhalation of stomach contents into the lungs.

Regular surveillance and adherence to treatment recommendations are essential to reduce these risks.

Med Surg Case Study #38: Daniel Shemoore