Sheet1Primordial PreventionPrimary PreventionSecondary PreventionTertiary PreventionQuaternary PreventionLung Cancer Colorectal CancerProstate CancerTesticular CancerAdult ImmunizationsPediatric ImmunizationsBreast CancerCervical CancerHuman PapillomavirusSexually Transmitted InfectionsSmoking / VapingHypertensionSuicideIntimate Partner ViolenceDepressionHepatitis CHepatitis BFall preventionCardiovascular Disorders PATIENT CASE Patient’s Chief Complaints “My acid reflux is getting worse and my histamine blocker isn’t working anymore. About an hour after a meal, I get a burning pain in the middle of my chest. Sometimes, I have trouble getting food down. It seems to get stuck behind my breastbone. I’ve never had that problem before. My heartburn is affecting my quality of life again and I want it to stop.” HPI W.R. is a 75 yo male with a significant history of GERD. He presents to the family practice clinic today for a routine follow-up visit. The patient reports that during the past three weeks he has experienced increasing episodes of post-prandial heartburn with some regurgitation and dysphagia. He has also begun using antacids daily in addition to histamine-2-receptor blockers for symptom relief. Despite sleeping with three pillows, the patient has also begun to experience frequent nocturnal awakenings from heartburn and regurgitation. PMH HTN × 15 years GERD × 7 years Alcoholic cirrhosis × 2 years Hiatal hernia FH Non-contributory SH Patient is widowed and lives alone; daughter daughter lives in same town, checks on him regularly, and takes him grocery shopping every Saturday Patient is a retired college basketball coach Enjoys cooking, traveling, gourmet dining, and playing poker (+) caffeine; 5 cups coffee/day (+) EtOH; history of heavy alcohol use; current EtOH consumption reported is 6 beers with shots/week (+) smoking; 55 pack-year history; currently smokes ¾ ppd Meds Verapamil SR 120 mg po QD Hydrochlorothiazide 25 mg po QD Famotidine 20 mg po Q HS Allergy Citrus fruits and juices (upset stomach) Dogs (itchy eyes, runny nose, sneezing) Erythromycin (unknown symptoms) ROS (−) H/A, dizziness, recent visual changes, tinnitus, vertigo (−) SOB, wheezing, cough, PND (+) frequent episodes of burning, non-radiating substernal CP (+) dysphagia (−) sore throat or hoarseness (−) N/V, diarrhea, BRBPR or dark/tarry stools (−) recent weight change PE and Lab Tests Gen The patient is a pleasant, talkative Native American man who is wearing a sports jacket, jeans, and tennis shoes. He looks his stated age and does not appear to be in distress. VS See Patient Case Table 25.1 Skin No rashes or lesions noted HEENT -PERRLA EOMI (−) arteriolar narrowing and A-V nicking Pink, moist mucous membranes (−) tonsils Oropharynx clear Lungs CTA Heart Regular rhythm (−) additional heart sounds Abd Normoactive BS Soft, NT/ND (−) HSM (−) bruits Genit/Rec (−) hemorrhoids (−) rectal masses Brown stool without occult blood Prostate WNL.

1. Sheet1Primordial PreventionPrimary PreventionSecondary
PreventionTertiary PreventionQuaternary PreventionLung
Cancer Colorectal CancerProstate CancerTesticular CancerAdult
ImmunizationsPediatric ImmunizationsBreast CancerCervical
CancerHuman PapillomavirusSexually Transmitted
InfectionsSmoking / VapingHypertensionSuicideIntimate
Partner ViolenceDepressionHepatitis CHepatitis BFall
preventionCardiovascular Disorders
PATIENT CASE Patient’s Chief Complaints “My acid reflux
is getting worse and my histamine blocker isn’t working
anymore. About an hour after a meal, I get a burning pain in the
middle of my chest. Sometimes, I have trouble getting food
down. It seems to get stuck behind my breastbone. I’ve never
had that problem before. My heartburn is affecting my quality
of life again and I want it to stop.” HPI W.R. is a 75 yo male
with a significant history of GERD. He presents to the family
practice clinic today for a routine follow-up visit. The patient
reports that during the past three weeks he has experienced
increasing episodes of post-prandial heartburn with some
regurgitation and dysphagia. He has also begun using antacids
daily in addition to histamine-2-receptor blockers for symptom
relief. Despite sleeping with three pillows, the patient has also
begun to experience frequent nocturnal awakenings from
heartburn and regurgitation. PMH HTN × 15 years GERD × 7
years Alcoholic cirrhosis × 2 years Hiatal hernia
FH Non-contributory
SH Patient is widowed and lives alone; daughter daughter lives
in same town, checks on him regularly, and takes him grocery
shopping every Saturday Patient is a retired college basketball
coach Enjoys cooking, traveling, gourmet dining, and playing
poker (+) caffeine; 5 cups coffee/day (+) EtOH; history of
heavy alcohol use; current EtOH consumption reported is 6
beers with shots/week (+) smoking; 55 pack-year history;

2. currently smokes ¾ ppd
Meds Verapamil SR 120 mg po QD Hydrochlorothiazide 25 mg
po QD Famotidine 20 mg po Q HS Allergy
Citrus fruits and juices (upset stomach) Dogs (itchy eyes, runny
nose, sneezing) Erythromycin (unknown symptoms)
ROS (−) H/A, dizziness, recent visual changes, tinnitus, vertigo
(−) SOB, wheezing, cough, PND (+) frequent episodes of
burning, non-radiating substernal CP (+) dysphagia (−) sore
throat or hoarseness (−) N/V, diarrhea, BRBPR or dark/tarry
stools (−) recent weight change PE and Lab Tests Gen The
patient is a pleasant, talkative Native American man who is
wearing a sports jacket, jeans, and tennis shoes. He looks his
stated age and does not appear to be in distress.
VS See Patient Case Table 25.1
Skin No rashes or lesions noted
HEENT
-PERRLA EOMI (−) arteriolar narrowing and A-V nicking Pink,
moist mucous membranes (−) tonsils Oropharynx clear
Lungs CTA Heart
Regular rhythm (−) additional heart sounds
Abd Normoactive BS
Soft, NT/ND (−) HSM (−) bruits
Genit/Rec (−) hemorrhoids (−) rectal masses Brown stool
without occult blood Prostate WNL
Ext (−) CCE
Neuro A & O for person, time, place CNs II–XII intact Strength
5/5 upper/lower extremities bilaterally
Patient Case Question 1. Which clinical information suggests
worsening symptoms of GERD in this patient? Patient Case
Question 2. Which symptom(s) indicates the possible severity of
the patient’s GERD? Patient Case Question 3. Are the patient’s
symptoms classic or atypical? Patient Case Question 4. Identify
all those factors that may be contributing to the patient’s
symptoms. Patient Case Question 5. Why is the drug verapamil
a potential contributing factor to the patient’s symptoms?
Patient Case Question 6. What non-pharmacologic therapies or

3. lifestyle modifications might be beneficial in the management
of this patient’s acid reflux disease? Patient Case Question 7.
What pharmacotherapeutic alternatives are available for the
treatment of this patient’s GERD?
Clinical Course The patient underwent upper endoscopy, which
revealed multiple, circular, confluent erosions of the distal
esophagus. There was no evidence of bleeding, ulcerations,
stricture, or esophageal metaplasia. The patient was treated with
an 8-week course of 30 mg/day lansoprazole and both heartburn
and dysphagia resolved. Approximately 10 weeks after PPI
therapy was discontinued, the patient reported that his reflux
symptoms had returned and that he was again suffering from
frequent post-prandial and nocturnal episodes of reflux. Patient
Case Question 8. What therapeutic options are now available for
this patient? Patient Case Question 9. Based on upper
endoscopy test results, what grade of esophagitis can be
assigned to this patient’s condition?
Bruyere, Harold J.. 100 Case Studies in Pathophysiology
(Kindle Locations 2538-2542). Wolters Kluwer Health. Kindle
Edition.