Gastroesophageal Reflux Disease: A Case Study Analysis

GASTROESOPHAGEAL
REFLUX DISEASE
-brief analysis of a case study

MEDICAL SYNOPSIS OF THE
PATIENT
 Name- Janet Swigel
 Age-68 year old
 Symptom is regurgitation after having meal and acidic
taste in the mouth.
 Difficulty in sleeping
 Symptoms are worst at night.

CASE HISTORY
PMH
Atrial fibrillation from last 12 years
Asthma from last 10 years
Type 2 DM from last 5 years
HTN from last10 years
SH
Consumes alcohol for 4-5 days per week.
She is having prescribed drug insurance
FH
Her mother died at the same age with
gastric cancer.
The patient is over weighted and her
blood pressure is also high. Previous
lab examinations revealed the
patient is having Grade B
Esophagitis. Biopsy result is
negative. The main question is, why
the patient is having a lot of
heartburn especially at night even
after some treatment.

IDENTIFYING THE PROBLEM
 The patient is taking aspirin on a daily basis and the main problem is self-
treatment.
 She is having heartburn 4-5 times a week and along with regurgitation after meal,
she feels acidic taste in her mouth.
 She cannot sleep at night
 After taking OTC Prevacid 24HR for 3 weeks daily, the heartburn reduced but
still it happen 3-4 times a week which is alarming and bothering the patient also.
 Her intake of alcohol can be a factor of GERD (Buendgens, Koch, & Tacke,
2016).