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ACID RELATED DISORDERS ADMITTING CONFERENCE AND TOPIC DISCUSSION
MENG MADDUMBA
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THE PT.GENERAL DATA
This is the case of DZG, 13/F, born on May 23 2001 BP: LMC, San Fernando City, La Union, POR: Dontogan, Baguio City, Student Roman Catholic Filipino
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HISTORYOF PRESENT ILLNESS
Admission
7 DAYS PTA(+) Epigastric pain
• after skipping meals, burning in nature • rated 5/10, localized, non-radiating• aggravated by an empty stomach, minimally relieved by food intake
(+) Dysuria and Increase in frequency of voiding(-) associated: N/V, Anorexia, diarrhea, febrile episodes, chest pains or DOB.
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HISTORYOF PRESENT ILLNESS
Admission
7 DAYS PTAConsult at a private clinic
Dx: ARD + UTIMeds Given:
• CEFIXIME BID (dosage unrecalled)• OMEPRAZOLE 20mg/tab OD
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HISTORYOF PRESENT ILLNESS
Admission
7 DAYS PTA(+) Epigastric pain(+) Dysuria(+) Consult
Dx: ARD + UTI
(-) associated S/Sx
6 DAYS – 2 DAYS PTA
(+) Dysuria and frequency of voiding decreasing up to two days PTA(+) Epigastric pain, same characteristics
• Decreasing pain rating from 6 to 2-3/10 • Decreasing in frequency from 3 to 1 episodes
(-) associated: N/V, Anorexia, diarrhea, febrile episodes, chest pains or DOB.
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HISTORYOF PRESENT ILLNESS
Admission
7 DAYS PTA(+) Epigastric pain(+) Dysuria(+) Consult
Dx: ARD + UTI
(-) associated S/Sx
6 DAYS – 2 DAYS PTA
(+) Epigastric pain(+) Dysuria(+) Consult
(-) associated S/Sx
Medications continued
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HISTORYOF PRESENT ILLNESS
Admission
7 DAYS PTA(+) Epigastric pain(+) Dysuria(+) Consult
Dx: ARD + UTI
(-) associated S/Sx
6 DAYS – 2 DAYS PTA
(+) Epigastric pain(+) Dysuria(+) Consult
(-) associated S/Sx
Medications continued
1 DAY PTA
(+) continuous epigastric pain after missing a meal.• Burning in nature, Rated 6-7/10,• Radiating to anterior chest area; left• Aggravated by intense training and minimally relieved by rest and
medications.
(+) Associated DOB and weakness(-) associated: N/V, Anorexia, diarrhea, febrile episodes, .
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HISTORYOF PRESENT ILLNESS
Admission
7 DAYS PTA(+) Epigastric pain(+) Dysuria(+) Consult
Dx: ARD + UTI
(-) associated S/Sx
6 DAYS – 2 DAYS PTA
(+) Epigastric pain
(-) associated S/Sx
Medications continued
(+) AssociatedDOB and weakness
1 DAY PTA FEW HRS PTA(+) Epigastric Pain
• Same characteristics• Rated 8-9/10
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HISTORYFEEDING HISTORY
At present, the diet is slightly below the patient’s daily calorie requirement
Based on a 2,500 kcal RENI of 13 year old female adolescent.
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HISTORYGROWTH AND DEVELOPMENTAL
Weight and Height:• Weight= 46 kg • Height= 1.57m• BMI: 18.66 = Normal
Physical growth:No reported delays in growthand Development.No observed impairments
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HISTORYGROWTH AND DEVELOPMENTAL
Psychological and Cognitive Development (HEADS)HOME
good interaction with family members
with occasional fights with siblings.
Still respectful of authorities and non-rebellious.
More concerned about his looks, clothes and body image.
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HISTORYGROWTH AND DEVELOPMENTAL
Psychological and Cognitive Development (HEADS)EDUCATION
More influenced by her peer groups in school though not rebellious towards authority.
Verbalized having hard time in more challenging academic requirement.
At present the patient’s developmental milestone is at par for age.
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HISTORYGROWTH AND DEVELOPMENTAL
Psychological and Cognitive Development (HEADS)ACTIVITIES
Physically Active Member of the National
Wushu Team Competes at International
competitionDRUGS
No history of use or plans of using
SUICIDE No grave problems that
would warrant suicidal ideologies
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HISTORYIMMUNIZATION STATUS
Claims to have complete immunization status
PAST MEDICAL
2001BETHANY HOSPITAL
LA UNION- Innocent Heart
Murmurs- Anemia
D/C WELL
2004SLU-HSH
- Pneumonia- Benign Febrile
Convulsions
D/C WELL
2007SLU-HSH
- Pneumonia
D/C WELL
Childhood illness: measles, mumps, UTI, and occasional cough and colds Allergies: No known allergies Medications: Omeprazole 20mg/tab OD
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HISTORYFAMILY DISEASES
Diseases in the Family:Both parents are presently well. Patient has a family history of HPN, Diabetes Mellitus, Arthritis, Colon cancer, CVD, and CAD.
No reported history of other heredofamilial diseases and other communicable diseases. No other persons residing in their home was noted
to have illness.
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REVIEWOF SYSTEMS
General: (-) weight loss, (-) fever, (-) chills, (-) sweats, (-) irritability, (+) poor oral intake, (+) weakness
Head and Neck: (-) trauma, (-) lesions, (-) swelling, (+) headache, (-) pain, (-) stiffness
Respiratory: (-) productive cough, (-) pain, (+) DOB, (-) hemoptysis, (-) cyanosis, (-) TB/PPKI
Cardiovascular: (-) edema, (-) cyanosis, (-) palpitation, (+) chest pains (-) murmur, (-) known CHD
GIT: (+) good oral intake; (-) anorexia, (+) abdominal pain, (-) vomiting, (-) nausea, (-) diarrhea, (-) constipation, (-) flatulence, (-) melena, (-) hematochezia, (-) change in bowel habits, (-) hernia, (+) use of laxatives or antacids, (-) jaundice, (-) hepatitisGUT: (-) dysuria, (-) frequency
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PHYS.EXPERTINENT FINDINGS
General Survey: Awake, conscious, coherent, afebrile, not in cardiorespiratory distress.
Vital Signs and Anthropometric MeasurementsCR= 98 bpm Weight= 46 kg RR= 24 cpm Height= 1.57mT= 36.6 C per axilla BMI: 18.66 = Normal
No signs of Dehydration
Chest/Lungs and Heart:SCWE (-)retractions, (-) lagging , clear breath sounds, adynamic precordium,(-) thrills, normal rate, regular rhythm, PMI located on the 5th LICS MCL, (-) murmur
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PHYS.EXPERTINENT FINDINGS
Abdomen: Flat, non-distended(+) normoactive bowel sounds (+) tympanitic on all four quadrants Soft (+) tenderness on epigastric area upon deep palpation, (-) masses palpated (-) organomegaly
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IMPRESSIONDIAGNOSIS OF THE PT
HISTORY (S)
Previous Dx:• Acid related
disorder• Under gastric
medications
History of:(+) Epig Pain (8-9/10)• Burning in nature• Radiating to chest• Precipitated by an
empty stomach• Aggravated by activity• Relieved by food
intake and medication(-) Febrile episode(-) N/V(-) Diarrhea
PHYS.EX (O)
Flat, non-distended Normoactive bowel sounds (-) Visible Mass and Pulsation (-) Palpated Mass Direct tenderness on
Epigastric area (-) pathologic gallbladder/
appendyceal signs
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IMPRESSIONDIAGNOSIS OF THE PT
Initial Impression: ARD – Gastroesophageal Reflux Disease (GERD)
DAY10
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PLANDIAGNOSTICS
URINALYSISUnremarkable Results
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PLANDIAGNOSTICS
CBCPNormochromic, normocytic RBCsNormal: Hgb, Hct, Platelets, WBC (neutrophilic predominance)
*Essentially normal
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PLANDIAGNOSTICS
Hook to D5NM 1li x 21 gtts/min computed at M%
Omeprazole 20 mg every 12 hoursAl + Mg Hydroxide (Maalox) 15 mL
every after meals
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DISCUSSION
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“'Acid-related disorders' is a term used to describe a whole range of conditions, where acid is entirely responsible for the problems. Careful evaluation of the patient's symptoms is required to establish the basis for the gastric problem”
Acid-related disorders: what are they? By: Colin-Jones DG
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“Five Components of the Evaluation of Children with Abdominal Pain
1. History2. Physical Examination3. Laboratory Tests4. Imaging Studies5. Empiric Interventions”
Chronic Abdominal Pain in Childhood: Diagnosis and ManagementALAN M. LAKE, M.D., Johns Hopkins University School of Medicine, Baltimore, MarylandAm Fam Physician.
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“Five Components of the Evaluation of Children with Abdominal Pain
1. History2. Physical Examination3. Laboratory Tests4. Imaging Studies5. Empiric Interventions”
Chronic Abdominal Pain in Childhood: Diagnosis and ManagementALAN M. LAKE, M.D., Johns Hopkins University School of Medicine, Baltimore, MarylandAm Fam Physician.
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More than one third of children complain of abdominal pain lasting two weeks or longer. The diagnostic approach to abdominal pain in children relies heavily on the history provided by the parent and child to direct a step-wise approach to investigation.
Chronic Abdominal Pain in Childhood: Diagnosis and ManagementALAN M. LAKE, M.D., Johns Hopkins University School of Medicine, Baltimore, MarylandAm Fam Physician.
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PHYSIOREVIEW
Two primary functional zones:A) oxyntic gland area (80% of the organ)B) pyloric gland area (remaining 20%)
Parietal cells (oxyntic glands) = hydrochloric acid and intrinsic factorChief cells (oxyntic glands) = pepsinogen. Neuroendocrine cells = regulate the activity of the parietal cell.
D cells enterochromaffin-like (ECL) cells A-like cells enterochromaffin (EC) cells.
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PHYSIOREVIEW
The principal stimulants for acid secretion are:a) Histamine
major paracrine stimulator of acid secretionb) Gastrin
main stimulant of acid secretion during meal stimulationc) Acetylcholine
directly stimulates acid secretion by binding to muscarinic (M3)
receptors
**released from postganglionic enteric neurons
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PHYSIOREVIEW
The principal stimulants for acid secretion are:a) Histamine
major paracrine stimulator of acid secretionb) Gastrin
main stimulant of acid secretion during meal stimulationc) Acetylcholine
directly stimulates acid secretion by binding to muscarinic (M3)
receptors
**released from postganglionic enteric neurons
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“Inflammation of the gastric and duodenal mucosa is the end result of an imbalance between mucosal defensive and aggressive factors. The degree of inflammation and imbalance between defensive and aggressive factors can then result in varying degrees of gastritis and/or mucosal ulceration.”
Pediatric gastritis and peptic ulcer disease.Blecker U1, Mehta DI, Gold BD.
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GERD
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Gastroesophageal reflux disease is the exposure of esophageal mucosa to
a) acidic gastric contentsb) Pepsinc) bile acids.
Can lead to: Esophageal mucosal injury: Erosive Esophagitis
GERDDISCUSSION
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Gastroesophageal reflux disease is the exposure of esophageal mucosa to
a) Acidic gastric contentsb) Pepsinc) Bile acids.
Can lead to: Esophageal mucosal injury: Erosive Esophagitis
GERDDISCUSSION
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Signs and symptoms (Infants – Younger Children): Typical or atypical crying and/or irritability Apnea and/or bradycardia Poor appetite; weight loss or poor growth (failure to thrive) Apparent life-threatening event Vomiting Wheezing, stridor Abdominal and/or chest pain Recurrent pneumonitis Sore throat, hoarseness and/or laryngitis Chronic cough Water brash
GERDDISCUSSION
CLINICAL PRESENTATION
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Signs and symptoms (Older Children):Signs and symptoms in older children include all of the
mentioned plus: Heartburn and a history of vomiting Regurgitation Unhealthy teeth Halitosis
GERDDISCUSSION
CLINICAL PRESENTATION
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DIAGNOSISGERDDISCUSSION
a)History and physical examinationb) Esophageal pH monitoringc) Combined multiple intraluminal impedance (MII) and pH
recordingd) Endoscopy and biopsye) Empiric trial of acid-suppressive as a diagnostic test
Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN).
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DIAGNOSISGERDDISCUSSION
“In infants and toddlers, there is no symptom or group of symptoms that can reliably diagnose GERD or predict treatment response. (B)”
Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN).
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DIAGNOSISGERDDISCUSSION
“In older children and adolescents a history and physical examination are generally sufficient to reliably diagnose GERD and initiate management.”
Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN).
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MANAGEMENTGERDDISCUSSION
TreatmentParental education, guidance, and supportLifestyle changesPharmacologic therapiesSurgical therapy
Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN).
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MANAGEMENTGERDDISCUSSION
Conservative measures: Providing small, frequent feeds thickened with cereal Upright positioning after feeding Elevating the head of the bed Prone positioning (infants >6 months)
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MANAGEMENTGERDDISCUSSION
Older Children: Diet that avoids tomato and citrus products, fruit juices,
peppermint, chocolate, and caffeine-containing beverages
Smaller, more frequent feeds Relatively lower fat diet (lipids retards gastric emptying) Proper eating habits Weight loss Avoidance of alcohol and tobacco, when applicable
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MANAGEMENTGERDDISCUSSION
Older Children: Diet that avoids tomato and citrus products, fruit juices,
peppermint, chocolate, and caffeine-containing beverages (?)
Smaller, more frequent feeds Relatively lower fat diet (lipids retards gastric emptying) Proper eating habits Weight loss Avoidance of alcohol and tobacco, when applicable
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MANAGEMENTGERDDISCUSSION
“In older children and adolescents, there is no evidence to support specific dietary restrictions to decrease symptoms of GER. In adults, obesity and late-night eating are associated with GER. (A)”
Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN).
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MANAGEMENTGERDDISCUSSION
“In older children and adolescents, there is no evidence to support specific dietary restrictions to decrease symptoms of GER. In adults, obesity and late-night eating are associated with GER. (A)”
Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN).
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MANAGEMENTGERDDISCUSSION
“In adolescents with GERD, left-side sleeping positioning and elevation of the head of the bed may decrease symptoms and GER. (A)”
Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN).
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MANAGEMENTGERDDISCUSSION
PHARMACOLOGYAntacids :
aluminum hydroxide, magnesium hydroxideHistamine H2 antagonists :
nizatidine, cimetidine, ranitidine, famotidineProton pump inhibitors:
lansoprazole, omeprazole, esomeprazole, dexlansoprazole, rabeprazole sodium, pantoprazole
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MANAGEMENTGERDDISCUSSION
“Histamine-2 receptor antagonists (H2RAs) produce relief of symptoms and mucosal healing. (A)
Proton pump inhibitors (PPIs) are superior to H2RAs in relieving symptoms and healing esophagitis. (A)”
Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN).
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MANAGEMENTGERDDISCUSSION
SURGICAL INTERVENTIONgastrostomy or fundoplication is required in only a very small minority of patients with gastroesophageal reflux
The goal of surgical antireflux procedures is to "tighten" the region of the lower esophageal junction and, if possible, to reduce hiatal herniation of the stomach
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MANAGEMENTGERDDISCUSSION
SURGICAL INTERVENTIONgastrostomy or fundoplication is required in only a very small minority of patients with gastroesophageal reflux
The goal of surgical antireflux procedures is to "tighten" the region of the lower esophageal junction and, if possible, to reduce hiatal herniation of the stomach
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MANAGEMENTGERDDISCUSSION
“Antireflux surgery should be considered only in children with GERD and failure of optimized medical therapy, or long-term dependence on medical therapy where compliance or patient preference preclude ongoing use, or life-threatening complications.(C)”
Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN).
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THANK YOU FOR LISTENING ADMITTING CONFERENCE AND TOPIC DISCUSSION
MENG MADDUMBA