subjective
Mr. Harrison, a 35-year-old man, submitted a Health Service Request form stating he felt like he has a “lump” in his throat. He stated that he has had it in the past, but it did not feel so big before, and he is concerned that he has a growth. He is seen in Nurse Sick call that day.
Nursing Sick Call Evaluation
The Nursing Sick Call evaluation included the following:
SUBJECTIVE
Mr. Harrison reports that he has had this feeling of a lump in his throat for the last 6 months “or so.” He also reports episodes of mild epigastric pain with occasional nausea. He has experienced bloating and belching. He has a dry cough and feels like he needs to clear his throat often. He sometimes has a sour taste in his mouth. In the free world, he would sometimes get canker sores in his mouth, but he has not experienced that since he’s been incarcerated (about a month). He also complains of an intermittent, burning type of pain to the anterior chest. It usually starts in the upper chest area and goes all the way up to the neck and throat area. He now is experiencing these symptoms almost daily since being at the facility. They become worse when he lies down or after eating. Even with all these symptoms, he did not get concerned until he started feeling that the lump was worsening.
Allergies: No known drug allergies; no known food allergies
Medications: None
OBJECTIVE
Vitals: T 98.8°F, P 82, R 20, BP 120/80, HT 6’4”, WT 198 lbs, BMI 24
General: Alert and cooperative. Sitting comfortably on exam table. Well nourished. No acute distress. Mildly anxious.
ENT/Mouth: Tympanic membranes clear; canals clear bilaterally. Nose with no nasal septal deviation; mucous membranes moist and pink. Throat with pink and moist oropharynx; no erythema, no tonsillar enlargement, no lesions, no tooth erosion. Mouth with no sores or lesions present.
Neck: Supple with no lymphadenopathy; thyroid normal size.
Lungs: Clear to auscultation bilaterally; no adventitious sounds.
Chest: Symmetric with no palpated tenderness.
Heart: S1S2, RRR; no murmurs, rubs or gallops.
Abdomen: Soft, non-distended and non-tender to palpation. Normoactive bowel sounds present in all quadrants.
CORRECTIONAL NURSE ACTIONS
Nursing Diagnosis: Intermittent chest and throat discomfort due to unknown etiology
Nursing Plan: Refer to provider clinic today
Mr. Harrison is then seen by the Provider
Provider Actions
Review of Systems
The patient’s Review of Systems is positive for nausea, bloating, belching, cough, past canker sores, chest pain, and repetitive throat clearing.
His Review of Systems is negative for sore throat, hoarseness, dysphagia, vomiting, abdominal pain, melena, weight loss, change in appetite, asthma, ear pain, tooth pain, or exertional type chest pain. He denies a cardiac history or hypertension. He does not smoke. He occasionally drank alcohol and daily drank caffeinated soda when he was not incarcerated. He denies any SOB or wheezing.
Relevant History
Mr. Harrison exercises regularly and has a history of Paget Schroetter syndrome at age 25. He was a high school teacher prior to incarceration. His family history includes diabetes and hypertension on both sides. His father, who is living, has a history of stage 4 throat cancer at age 55, and Mr. Harrison is very concerned that the “lump” he feels is getting bigger is cancer.
Provider physical assessment results were the same as the nurse’s – unremarkable.
Differential Diagnoses for MR. Harrison
Hiatal hernia is a condition where a portion of the stomach protrudes through the diaphragm into the thoracic region. Most hiatal hernias do not produce symptoms but are often found incidentally after radiology testing. However, esophageal reflux and its symptoms (heartburn, abdominal discomfort, throat irritation, belching, and regurgitation) may be associated with the presence of a hiatal hernia.
Peptic ulcer disease is most often seen in patients using NSAIDs or with a history of Helicobacter pylori infection. This can be evaluated with an H. pylori breath test and endoscopy if treatment fails. This patient was not on NSAIDs and had no history of H. pylori infection, making this a less likely diagnosis.
Malignancy is unlikely in this case because the patient is relatively young, and he has not had any unexplained weight loss. However, because of the patient’s sensation in the throat and a family history of throat cancer, this must be explored.
Laryngopharyngeal reflux, also known as silent reflux, has atypical reflux-like symptoms. This patient does not have sore throat or hoarseness, which are two common symptoms of laryngopharyngeal reflux. This patient presents with chest pain, so another diagnosis is more likely.
Gastroesophageal reflux disease has a high prevalence in the U.S. population. Heartburn-like symptoms are the most common complaint, and this patient has atypical chest pain and heartburn-like symptoms. He also has a chronic cough and some nausea. He has a globus sensation, a feeling of a lump in the throat, which is also a symptom.
Coronary artery disease should always be ruled out first in patients who complain of chest pain. This is not the likely diagnosis in this case as the patient has no exertional chest pain, is relatively young, and has no personal or family history of cardiac disease.
Most Likely Diagnosis: GERD
Gastroesophageal reflux disease. Based on the patient’s age and presenting symptoms, GERD is the most likely diagnosis. His mild epigastric pain, burning sensation in the chest (likely heartburn), sensation of the lump in the throat, bloating, and cough all support this to be the most likely diagnosis.
Diagnostic Tests/Imaging
Initial diagnostics are not warranted for patients with symptoms suggestive of uncomplicated reflux disease. If treatment response is as expected, no further imaging/testing is required.
An EKG might be ordered in cases of “atypical” manifestations of GERD including non-cardiac chest pain. This would be to rule out an underlying cardiac etiology if this symptom were present, including angina or other ischemic diseases.
Testing for H. pylori is only indicated for patients with a history of active peptic ulcer disease, MALT lymphoma, or dyspepsia with local prevalence >10%. It is not indicated as a first-line assessment in patients with uncomplicated GERD.Subsequent follow-up evaluations may include an upper endoscopy for persistent symptoms despite treatment. This would be to document the type and extent of tissue damage secondary to GERD.
Pathophysiology
GERD
In normal function, the Lower Esophageal Sphincter (LES) provides a barrier to reflux of acid from the stomach going back into the esophagus. Additionally, esophageal peristalsis waves toward the stomach when the sphincter is relaxed is meant to ensure that stomach acid does not reflux into the esophagus. Loss of sphincter tone, increasing frequency of sphincter relaxation, loss of esophageal peristalsis, increased stomach volume and pressure (i.e., with obesity), or increased acid production will contribute to reflux of acidic stomach contents into the esophagus. Acute reflux of acid into the esophagus will cause pain or erosion of the esophageal mucosa. Recurrent damage to the mucosa will result in inflammation and damage at the cellular level.
Hiatal hernias are found in one-fourth of patients with non-erosive GERD, 75% of patients with severe erosive esophagitis and over 90% of patients with Barrett esophagus. They are caused by the movement of LES above the diaphragm, resulting in dysfunction of the gastroesophageal junction reflux barrier.
Prevalence, Treatment Approach, and Risk Associated with Long-Term Medication
GERD affects 18% to 28% of adults in the United States. It is a common chief complaint and one PCPs see frequently. Many patients perceive GERD as a life-limiting disease. Patients have difficulties with diet and lifestyle changes required to manage their disease and require ongoing support, resources, and understanding. Patients require monitoring to ensure that any complications or worsening of symptoms is caught quickly.
Plan
Prescribe a H2 blocker – pepcid
Recommendations on Lifestyle Management to reduce symptoms.
Schedule a follow-up in 2 weeks to determine initial response to treatment and decide if referral to a GI specialist is necessary. Inform the patient of the importance of notifying health staff immediately if symptoms suddenly worsen or new symptoms develop.
Patient Education
The patient education includes dietary changes, alcohol and tobacco use, sleep position, and weight loss. Even though many GERD patients are advised to avoid certain foods, there is not much evidence to support this recommendation. However, weight loss, quitting smoking, elevating the head of the bed, and avoiding late evening meals can significantly reduce symptoms.
After Lifestyle Modifications, initiating acid suppression medications is the next step. These include antacids, histamine-receptor antagonists, and PPIs. Among them, PPIs are the preferred medication. Surgical therapy is the last step and usually reserved for patients who do not respond well to acid suppression medication, patients who prefer surgical approach, and patients who present with complications due to GERD.
Comments
Evolving studies demonstrate some side effects when the patients are on medications for long-term management of GERD. The long-term use of PPIs may have the following risks: (a) malabsorption of calcium, magnesium, and vitamin B12, which can lead to bone fractures; (b) increased risk of community-acquired pneumonia and enteric infections; (c) interactions with cytochrome P450 isozyme 2C19, which can result in interference with metabolism of other co-administered drugs (clopidogrel); (d) increased risk of chronic kidney disease; and (e) an association with microscopic colitis. Primary Care Providers should have a good understanding about the long-term use of PPIs and potential risks.
Previously, PPIs were one of those most commonly prescribed medications worldwide and have been the mainstay of treatment for GERD. Emerging data are showing an association between long-term PPI use and bone fractures, Clostridium difficile infection, pneumonia, MI, and stroke. Potent acid suppression has now been shown to increase the reflexive production of gastrin.
Multiple observational studies suggest that long-term use of PPIs is also associated with a higher risk of gastric cancer development. This is significant given the widespread use and OTC availability of PPIs. It is important to advise a patient of this and determine medication based on risks and benefits. All information provided regarding the risks, benefits, and side effects of medication should be documented in a patient’s medical record. Persistent, untreated esophageal reflux, from whatever underlying cause, will result in recurrent injury and over time strictures, pain, obstruction, perforation, or Barrett esophagus. Patients with Barrett esophagus have an 11-fold increased risk of esophageal carcinoma compared to patients without Barrett esophagus.
GERD is a common complaint that can mimic other diseases. It is important to get a good history. Communication from provider to the patient is important as well as explaining the diagnosis in a way the patient can understand. This patient was at a higher risk as his father had severe GERD that resulted in throat cancer. His father’s history caused the patient to worry even more. He was worried he would develop throat cancer. It was a great opportunity to discuss with the patient the importance of following the treatment plan as well as the importance of regular follow-up and Lifestyle Modifications.
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*As always, your company or facility policies, procedures and Nursing Protocols/Guidelines take precedence over any written recommendations on this website.
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