Fluent Essays

Instructions and study case attached For this assignment, you will complete a Aquifer case study based on the course objectives and weekly content. Aquifer cases emphasize core learning objectives for an evidence-based primary care curriculum. Throughout your nurse practitioner program, you will use the Aquifer case studies to promote the development of clinical reasoning through the use of ongoing assessments and diagnostic skills and to develop patient care plans that are grounded in the latest clinical guidelines and evidence-based practice. The Aquifer assignments are highly interactive and a dynamic way to enhance your learning. Material from the Aquifer cases may be present in the quizzes, the midterm exam, and the final exam. Learn how to access and navigate Aquifer. This week, complete the Aquifer case titled “Family Medicine 19: 39-year-old man with epigastric pain” Apply information from the Aquifer Case Study to answer the following discussion questions: · Discuss the Mr. Rodriquez’s history that would be pertinent to his gastrointestinal problem. Include chief complaint, HPI, Social, Family and Past medical history that would be important to know. · Describe the physical exam and diagnostic tools to be used for Mr. Rodriguez. Are there any additional you would have liked to be included that were not?  · Please list 3 differential diagnoses for Mr. Rodriguez and explain why you chose them.  What was your final diagnosis and how did you make the determination? · What plan of care will Mr. Rodriquez be given at this visit, include drug therapy and treatments; what is the patient education and follow-up? Today, you are working at a family medicine clinic with Dr. Medel. Together, you review her clinic schedule for the day and she suggests that you see Mr. Cesar Rodriguez, a 39-year-old uninsured male who recently moved to the U.S. from the Dominican Republic. This is Mr. Rodriguez's first visit to the clinic. Molly, Dr. Medel's medical assistant, has already escorted Mr. Rodriguez to the examination room and has arranged for a Spanish-speaking interpreter to be present for the visit, since he speaks and comprehends very little English. Molly tells you that Mr. Rodriguez has been having "worsening abdominal pain over the past several months" and is "worried that something is wrong." Dr. Medel says to you, "How would you begin to think about what might be going on with Mr. Rodriguez?" You reply, "Abdominal pain can be caused by a wide variety of conditions. I'll need to get more information about his symptoms to form an appropriate differential diagnosis. At this point I'd have to consider several organ systems as potential etiologies of the pain." "Very good," Dr. Medel responds. "Why don't you go ahead and talk with Mr. Rodriguez and come find me afterward. Lola, our Spanish-speaking interpreter, can help." TEACHING POINT Systems Approach to Abdominal Pain Gastrointestinal Appendicitis, cholecystitis/cholelithiasis, diverticulitis/diverticulosis, dyspepsia, gastroesophageal reflux disease, gastritis, acute or chronic hepatic failure with resulting complications (e.g., ascites), acute hepatitis (e.g., viral, autoimmune, alcoholic, drug-induced), inflammatory bowel disease, intestinal ischemia, intestinal obstruction, irritable bowel syndrome, pancreatitis, peptic ulcer, perforation/peritonitis (e.g., gastric, colonic, intestinal), gastric outlet obstruction, tumor (e.g., gastric, hepatic, pancreatic, intestinal, colonic).  Cardiac Myocardial infarction, angina pectoris, abdominal aortic aneurysm dissection or rupture. Psychogenic Anxiety, panic disorder, somatoform disorder, post-traumatic stress disorder.  Pulmonary Pleurisy, lower lobe pneumonia, pulmonary infarction, tumor.  Renal Nephrolithiasis, pyelonephritis, cystitis, tumor. Musculoskeletal Abdominal wall muscle strain, hernia (e.g., ventral, inguinal, incarcerated), abscess (e.g., psoas, subphrenic), trauma (e.g., contusion, hematoma), cutaneous nerve entrapment. Metabolic Drug overdose, ketoacidosis, iron or lead poisoning, uremia, acute intermittent porphyria. Also consider: · Medication, vitamin, and herbal supplement side effects · Dietary factors (dietary intolerances, such as lactose, gluten, fructose, or artificial sweeteners [e.g., sorbitol, xylitol, sucralose]) TEACHING POINT How to Interview a Patient Via an Interpreter · Speak as you would normally, directly to the patient and not to the interpreter. · The interpreter should interpret in the first person, without editing it in any way. · Often, the interpreter will sit just behind the patient and in their ear, or off to the side where the interpreter won't obstruct your ability to face the patient, make direct eye contact, and feel like you're talking with the patient directly. · Ideally, it should feel like the interpreter is just a conduit for the conversation between you and the patient. As you walk down the hall, Lola, the Spanish-speaking interpreter, gives you some tips on how to interview a patient with an interpreter. You and Lola enter the room. You sit directly across from Mr. Rodriguez, with Lola sitting just off to your left and facing him. You sense that Mr. Rodriguez seems anxious about coming to the physician today. You introduce yourself and ask, "What brings you in today?" "Is there anything that makes the pain better or worse?" "What worries you the most about your symptoms?" Thinking about some of the common causes of abdominal pain, you conduct a focused review of systems: · General: Reports no weight loss, fevers, chills, or night sweats. He has had no recent illnesses. Aside from a recent move to the U.S. from the Dominican Republic, he has not traveled recently. · GI: Reports no dysphagia, regurgitation, nausea, vomiting, anorexia, early satiety, hematemesis, hematochezia, melena, diarrhea, or constipation. · GU: Reports no dysuria, hematuria, or change in frequency. · CVS/Respiratory: Reports no chest pain, cough, or shortness of breath. MEDICAL AND FAMILY HISTORY HISTORY You now direct your attention to Mr. Rodriguez' medical history. "Do you have any chronic medical problems?" "Have you ever been hospitalized or had any surgeries?" "Do you take any medicines or supplements?" "Does anyone in your family have any medical conditions—for example, heart or blood pressure problems? Diabetes?" "Does anyone in your family have stomach problems or pain similar to yours?" You ask Mr. Rodriguez a few more questions and discover that he works as a farm laborer. He has no known drug allergies. He smoked a few cigarettes daily but quit six months ago. He drinks three to four beers per week. He reports no other drug use. He has had no recent illnesses. Aside from a recent move to the U.S. from the Dominican Republic, he has not traveled recently. You congratulate Mr. Rodriguez on quitting smoking and you thank him for answering all of your questions. You review in your mind what you've learned from Mr. Rodriguez so far, and find yourself still wondering about why he seems a little anxious. Before you go to get Dr. Medel, you inquire, "It seems like this has really been bothering you. Is there anything else we haven't talked about that seems important?" ACCESS TO CARE TEACHING You reply, "Well, I'm glad you came in today, and I'll be sure and share your concern with Dr. Medel. Thanks for telling me." You ask him to change into a gown, taking off his clothes. You reassure him that you will return with Dr. Medel momentarily, and you and Lola leave the exam room while Mr. Rodriguez changes. In the hallway, you comment to Lola that you are concerned about why Mr. Rodriguez waited to come see a doctor. DIFFERENTIAL DIAGNOSIS CLINICAL REASONING Dr. Medel praises your summary and then asks you to commit to a provisional differential diagnosis for Mr. Rodriguez's abdominal pain, based on your findings from his history. Question From the following, select the top three diagnoses on your differential. The best options are indicated below. Your selections are indicated by the shaded boxes. · A. Abdominal wall muscle strain · B. Acute Pancreatitis · C. Angina pectoris · D. Anxiety · E. Diverticulitis · F. Gastritis · G. Gastroesophageal reflux disease (GERD) · H. Peptic ulcer disease (PUD) · I. Pneumonia SUBMIT Answer Comment The correct answers are F, G, H. TEACHING POINT Differential for Chronic Progressively Worsening Upper Abdominal Pain Most Likely / Most Important Diagnoses Gastritis · Inflammation or irritation of the stomach lining often causing sharp epigastric pain. This pain may be variably worsened or improved with eating food. · Inflammatory forms of gastritis may be caused by chronic infections, such as  H. pylori, or acute infections, such as enterovirus. · Noninflammatory forms of "gastritis" are histologically termed gastropathy. These may be caused by chemical irritants to the stomach, including alcohol and medications. GERD · May present with mild epigastric pain and symptoms commonly worsen after meals, although the pain is classically described as "burning" and is typically located in the substernalrather than epigastric area. · May be associated with regurgitation and, rarely, dysphagia. · Hematemesis in the setting of GERD-like symptoms is unusual and represents an alarm symptom indicative of an upper GI bleed warranting prompt GI referral for evaluation and upper endoscopy. · Nausea, vomiting, hematochezia, and melena are not typically associated with GERD. Peptic ulcer disease (PUD) · Epigastric abdominal pain that improves with meals is the hallmark of PUD. However, in some cases, symptoms of PUD may worsen with meals. · NSAID use is associated with the development of PUD. · Hematemesis, if present, suggests more complicated disease, such as bleeding ulcer, and warrants urgent GI referral and endoscopy.  · Melena commonly occurs in the setting of an upper GI bleed secondary to PUD or hemorrhagic gastritis (e.g., NSAID-gastritis). Hematochezia only occurs in the setting of an upper GI bleed when massive (e.g., variceal rupture).  Less Likely Diagnoses Abdominal wall muscle strain · Unlikely in the absence of a positional component to the pain. Acute pancreatitis  · Causes severe abdominal pain, associated with nausea and vomiting, ill appearance on exam, and clinical signs of dehydration such as tachycardia. · Pain is typically located in the epigastric area with radiation to the back, improves with leaning forward, and worsens with eating. Symptoms often last for many hours without relief. · Leads to elevations in serum lipase and amylase. · Acute and chronic pancreatitis are most commonly caused by alcohol useand gallstones. Remember that some patients may not be forthcoming about their actual alcohol use, especially if they perceive they are being judged or if they are in denial about problem use/abuse. Angina pectoris · Classically presents with substernal chest pain, but may present with epigastric abdominal pain and nausea or vomiting. · Interestingly, GERD is the most common cause of noncardiac chest pain (NCCP). Anxiety · A possible etiology for abdominal pain, but other diagnoses should always be considered first. · Can be associated with additional types of body pain, and patients who have anxiety disorders may self-medicate (i.e., with alcohol), which may warrant further careful exploration. Diverticulitis  · Classically presents with acute left lower quadrant abdominal pain, change in bowel movements, and fever. · Most common in patients over 50 years of age. Pneumonia · Unlikely in the absence of pulmonary symptoms and fever. The absence of hematemesis, hematochezia, or melena is reassuring that significant GI bleeding is unlikely to be present, but does not help to distinguish between these three diagnoses, all of which commonly present without GI bleeding. DYSPEPSIA DEFINED After careful consideration, you tell Dr. Medel that you are concerned that Mr. Rodriguez has either gastritis, gastroesophageal reflux disease (GERD), or peptic ulcer disease (PUD). You and Dr. Medel discuss the various causes of dyspepsia. You tell Dr. Medel you are confused as to how to differentiate the etiologies of dyspepsia. Dr. Medel replies, "That is understandable, as this is like piecing together a puzzle. There is no one right answer for every patient. Instead, you have to consider the clinical picture as a whole. We'll need to consider each possible etiology for dyspepsia for Mr. Rodriguez." TEACHING POINT Dyspepsia: Definition, Symptoms, Epidemiology, and Etiology Definition Dyspepsia is literally "bad digestion." Patients commonly describe having "indigestion." Symptoms Patients with this condition experience upper abdominal pain or discomfort that is episodic or persistent. It is often associated with belching, bloating, heartburn, early satiety, nausea, and/or vomiting. Epidemiology About a quarter of adults are affected by dyspepsia, but many people self-diagnose and self-treat. Even though most people don't seek medical care for it, dyspepsia accounts for approximately 5% of all visits to family physicians and is the most common symptom leading to GI referral in the U.S. Etiology Condition % of Dyspepsia Cases Functional or non-ulcer dyspepsia (specific etiology for dyspepsia can't be identified) ~ 50% Peptic ulcer disease (PUD) 20% GERD 20% Gastritis / duodenitis 10% Medication side effects Common Pancreatitis Less common Gastric, pancreatic, and esophageal cancer Important though uncommon (< 2%) Non-GI causes (such as angina and dissecting aortic aneurysm) Rare, but should always be included in ddx CAUSES OF DYSPEPSIA You tell Dr. Medel that you are still unsure how to differentiate between dyspepsia due to gastroesophageal reflux disease (GERD) and dyspepsia due to peptic ulcer disease (PUD). Question Which of the following are TRUE regarding dyspepsia due to GERD or PUD? Select all that apply. The best options are indicated below. Your selections are indicated by the shaded boxes. · A. GERD can be distinguished from other gastrointestinal disorders with reasonable accuracy on the basis of symptoms. · B. Eating and drinking make GERD symptoms improve and PUD symptoms worse. · C. Peptic ulcers may be associated with nausea and vomiting that can occur anytime shortly after eating up to several hours later. · D. Non-erosive reflux disease (NERD) is the most common form of GERD. · E. Patients with GERD report lower health-related quality of life than patients with heart failure. SUBMIT Answer Comment The correct answers are A, C, D, E. The symptoms that patients describe often overlap and can make it tricky to determine the etiology of dyspepsia. However, some symptoms can help distinguish GERD from other gastrointestinal disorders with reasonable accuracy. TEACHING POINT Peptic Ulcer Disease Versus Gastroesophageal Reflux Disease Symptoms Some symptoms of PUD directly contrast those of GERD. PUD GERD Characterized by episodic or recurrent epigastric "aching," "gnawing," or "hunger-like" pain or discomfort  Classic symptoms of retrosternal heartburn and regurgitation Symptoms occur on an empty stomach and are commonly relieved by meals More likely to occur when gastric volume is increased (after large meals) However, this is not always true, and there can be some differences in symptoms based on the location of an ulcer. For example, gastric ulcer pain may occur 5 to 15 minutes after eating and remain until the stomach empties, which may be up to several hours in duration; the pain may otherwise be absent during times of fasting. Pain from duodenal ulcers is often relieved by eating, drinking milk, or taking antacids but may return anywhere from 90 minutes to four hours after eating a meal. Both gastric and duodenal ulcers may be associated with nausea and vomiting occurring anytime shortly after eating to several hours later. Given the population prevalence of obesity and hiatal hernia, conditions that predispose a patient to GERD, it is not uncommon for a patient with PUD to also have GERD. TEACHING POINT Gastroesophageal Reflux Disease: Pathophysiology, Symptoms, Complications, and Quality of Life Pathophysiology GERD is a chronic relapsing condition in which gastric contents reflux through the lower esophageal sphincter (LES) into the esophagus and oropharynx. Transient LES relaxations are believed to be the primary etiologic factor. Ineffective esophageal clearance (as seen with scleroderma, for example) and delayed gastric emptying (as seen with gastroparesis, for example) may also be contributing factors in some patients. Increased intra-abdominal pressure is also a predisposing factor (obesity/central adiposity, pregnancy, constricting garments), especially in the presence of hiatal hernia. Symptoms 1. Gastroesophageal reflux: epigastric burning that sometimes radiates to the throat and tends to worsen when: · gastric volume is increased (after large meals) · gastric contents are located near the gastroesophageal junction (reclining or bending) · intra-abdominal pressure is increased (such as with obesity, pregnancy, abdominal binders, or girdles). 2. Esophageal spasm: sharp, stabbing, substernal pain that can be triggered by temperature extremes (e.g., hot coffee, ice water). Heartburn, esophageal reflux, and esophageal spasm commonly occur at night or after the consumption of trigger foods or a large meal. Symptoms of GERD may also be precipitated by: · Spicy, acidic, and fatty foods · Chocolate · Mint · Smoking · Alcohol and caffeine · Eating large portions · Lying flat after a meal · Wearing tight clothing around the waist · Some medications (calcium channel blockers, beta-agonists, alpha-adrenergic agonists, theophylline, nitrates, and some sedatives) When severe reflux reaches the pharynx and mouth or is aspirated, it can cause atypical signs and symptoms of GERD or laryngopharyngeal reflux (LPR). Atypical symptoms may point to (but don't sufficiently support by themselves) a diagnosis of GERD. Atypical signs and symptoms of GERD: · Asthma, especially new onset in an adult with no history of atopy · Chronic cough · Dental enamel loss · Globus sensation · Hoarseness · Noncardiac chest pain · Recurrent laryngitis · Recurrent pharyngitis · Subglottic stenosis Complications About 60% of cases of GERD can be classified as non-erosive reflux disease (NERD). Unfortunately, symptom frequency, duration, and severity do not help to differentiate the grade of esophagitis and cannot be used to reliably diagnose complications of GERD. Quality of life Patients who have GERD generally report decreased quality of life, reduced productivity, and decreased well-being. In many patients, reported health-related quality of life is lower than age-matched patients who have untreated angina pectoris, diabetes mellitus or chronic heart failure. COMPLICATIONS AND ALARM SIGNS TEACHING You and Dr. Medel discuss complications of GERD and PUD. Dr. Medel tells you about alarm symptoms, concluding, "Mr. Rodriguez does not demonstrate any of these right now, but we should remember them, because any of these symptoms would warrant timely referral to a gastroenterologist for endoscopy." TEACHING POINT Complications of GERD and PUD GERD · Esophagitis develops when the mucosal defenses that normally counteract the effect of injurious agents are overwhelmed by refluxed acid, pepsin, or bile. · Peptic strictures from fibrosis and constriction occur in about 10 percent of patients with reflux esophagitis. · Replacement of the squamous epithelium of the esophagus by columnar epithelium (Barrett's esophagus) may result from reflux esophagitis. Two to five percent of cases of Barrett's esophagus may be further complicated by adenocarcinoma. PUD · Hemorrhage  or  perforationinto the peritoneal cavity or adjacent organs may occur, causing severe, persistent abdominal pain. · Duodenal ulcer, inflammation, and fibrotic scarring can impair gastric emptying due to gastric outlet obstruction. TEACHING POINT Alarm Symptoms Warranting Referral to Gastroenterology for Endoscopy Dysphagia Difficulty in swallowing. Dysphagia to solids suggests possible peptic stricture. Rapidly progressive dysphagia potentially indicates carcinoma. Dysphagia to liquids suggests a motility disorder. Dysphagia to both solids and liquids suggests obstruction—for example, achalasia (closed LES) or tumor. Initial onset of upper GI symptoms after age 50 Increased chance of cancer.  Older age at onset increases likelihood of organic disease (PUD, cancer) rather than functional dyspepsia or non-erosive reflux disease (NERD). NERD meets the same diagnostic criteria as GERD but shows no erosions on endoscopy. Early satiety May be associated with gastroparesis or gastric outlet obstruction (stricture or cancer). Hematemesis Vomiting blood suggests bleeding ulcer, mucosal erosions (erosive gastritis/esophagitis), esophageal tear (Mallory-Weiss), or esophageal varices.  Hematochezia Passing red blood with stool may indicate a rapidly bleeding ulcer or mucosal erosions.  Iron deficiency anemia The presence of hematemesis, hematochezia, and/or iron deficiency anemia may indicate possible bleeding from a peptic ulcer, mucosal erosions, or cancer. Odynophagia Painful swallowing, which is associated with infections (e.g., candida, CMV, HSV), erosions, or cancer.  Recurrent vomiting Suggestive of gastric outlet obstruction. Weight loss Associated with malignancy. PREPARING FOR THE PHYSICAL EXAM TEACHING Now Dr. Medel says, "Let's think about how the physical exam might help us narrow our differential. What do you think?" "That's a trick question!" you exclaim. "In most cases of patients presenting with symptoms related to GERD and PUD, the physical examination will be normal. But we will want to look for signs of complications." Dr. Medel replies, "You're right. We will want to look for signs of complications, as well as signs of other diseases that could be associated with dyspepsia." TEACHING POINT GERD/PUD Physical Exam: Signs of Complications or Other Associated Diseases Hemodynamic status Hypotension or tachycardia may indicate significant blood loss from a gastrointestinal bleed. Signs of anemia Brittle nails and cheilosis (cracks and sores on the lips) are signs of anemia. Pallor of palpebral (eyelid) mucosa or nail beds may also be present with anemia. Tachycardia or heart murmur can be a sign of anemia. Signs of malignancy Weight loss, palpable mass, presence of signal lymph nodes (Virchow node), and acanthosis nigricans (velvety, hyperpigmented skin, usually on the neck, under the arms, or in the groin) are signs of possible malignancy. Signs of gallbladder disease Jaundice or a positive Murphy's sign. A test for Murphy's sign is performed by asking the patient to breathe out and then gently placing the hand in the approximate location of the gallbladder. The patient is then instructed to inspire. If the patient stops inhaling (as the tender gallbladder comes in contact with the examiner's fingers) the test is considered positive. Signs of hypo or hyperthyroidism Constipation, cool or pale skin, coarse hair, or non-pitting edema (myxedema) or delayed relaxation phase of deep tendon reflexes (DTRs) may be present in hypothyroidism. Diarrhea, warm skin, thinning hair, eyelid lag, brisk DTRs, or tachycardia may be present in hyperthyroidism. Though a very rare cause of dyspepsia, thyroid disease should be considered. PHYSICAL EXAM You knock on the door and ask Mr. Rodriguez if he is ready for you, Lola, and Dr. Medel to re-enter the exam room. Mr. Rodriguez says "Yes," and you proceed with your exam, which reveals: Vital signs: · Temperature is 36.9 C (98.5 F) · Pulse is 78 beats/minute, regular · Respiratory rate is 16 breaths/minute · Blood pressure is 123/72 mmHg · Body mass index is 24.8 kg/m2 General: Well-appearing, middle-aged man. Head, eyes, ears, nose, and throat (HEENT): Sclera anicteric, no conjunctival pallor, oropharynx without lesion or significant dental abnormality. Neck: Supple, no mass, lymphadenopathy, or thyromegaly. Cardiovascular: Regular heart rate and rhythm, S1, S2, no murmurs, rubs, or gallops. Respiratory: Bilaterally clear to auscultation and percussion without wheezes, rales or rhonchi. Abdominal: Symmetric appearance without scars or ecchymosis. Normoactive bowel sounds heard in four quadrants. Soft, nondistended, with minimal epigastric tenderness on deep palpation without rebound tenderness or guarding, no hepatosplenomegaly, and no herniae or masses. Skin: Tanned; no jaundice, several tattoos on his upper extremities, no suspicious lesions. Extremities: Warm and well-perfused, no cyanosis, clubbing or edema. You inform Mr. Rodriguez that his symptoms and physical examination so far do not seem to indicate a serious medical problem and tell him that you are going to step out to give him a chance to dress. Seeing Mr. Rodriguez relax a bit in his chair, you feel that he seems somewhat reassured. DIAGNOSIS AND TREATMENT PLAN MANAGEMENT You and Dr. Medel discuss your findings and consider a diagnosis and treatment plan. She agrees with your assessment that it is challenging to accurately diagnose Mr. Rodriguez with either non-ulcer dyspepsia, GERD or PUD, or gastritis given the history and exam findings alone. Dr. Medel asks "Is there anything about Mr. Rodriguez today that seems to be an urgent concern?" Question Next, she asks: "Which two of the following options are the most appropriate first steps in diagnostic testing and therapeutic planning for this patient?" Choose the two best answers. The best options are indicated below. Your selections are indicated by the shaded boxes. · A. Using an empiric treatment strategy with a proton pump inhibitor (PPI) · B. Referring the patient for an upper endoscopy (esophagogastroduodenoscopy / EGD) · C. Ordering an upper GI series (barium swallow radiograph) · D. Focusing on lifestyle modifications to promote symptomatic improvement · E. Referring the patient for a 24-hour pH probe SUBMIT Answer Comment The correct answers are A, D. TEACHING POINT Empiric Treatment for GERD, Gastritis, and PUD An empiric treatment strategy for GERD, gastritis, and PUD is the most widely accepted initial therapeutic intervention in patients without red flag symptoms. The empiric treatment strategy for a patient who exhibits the classic symptomatology of GERD with heartburn and regurgitation begins with a self-directed trial of over-the-counter anti-secretory therapy, either a histamine-2 receptor antagonist or a proton-pump inhibitor (PPI). Many patients consult their primary care physicians because their symptoms have persisted, or because they would like a prescription, which may reduce their out-of-pocket cost for anti-secretory therapy. Several randomized trials have demonstrated that the "PPI test," defined as a short-term trial of prescription-strength PPI, is both sensitive and specific for diagnosing GERD in patients with classic symptoms and can significantly reduce the need for upper endoscopy/EGD and 24-hour pH monitoring. This test has been shown to save over $350 per patient evaluated, reduce upper endoscopies by 64%, and reduce the number of esophageal monitoring tests by 53%. The natural history of both GERD and nonulcer dyspepsia are variable, and antisecretory therapy should be stopped after a successful four- to eight-week course, or used in a pulse dose manner (daily for short periods of time when symptoms recur). Addressing lifestyle modifications with patients who report symptoms of GERD and dyspepsia is a reasonable approach to therapy. There is reported benefit in some patients and expert opinion suggests that dietary/lifestyle changes be encouraged in patients with GERD, although there is little evidence to support improvement in symptomatic outcomes in the absence of pharmacotherapy. Patients should be referred for upper endoscopy/EGD in the setting of alarm or extraesophageal symptoms to rule out significant disease, or in cases that do not respond to empiric treatment strategy after eight weeks. The upper GI series can be useful in determining complications of GERD (e.g. esophageal stricture), but has poor utility in diagnosing GERD and should not be used for this purpose. In some cases, the upper GI series may reveal a gastric or duodenal ulcer, but it is not the gold standard test to make this diagnosis. The 24-hour pH probe is most appropriately utilized when the diagnosis of GERD cannot easily be determined, when patients desire referral for surgical treatment of their GERD/hiatal hernia (Nissen fundoplication) or when patients with classic symptoms of GERD (heartburn, regurgitation) do not improve after appropriate trials of several different PPIs. SHARING TREATMENT PLAN Together, you, Dr. Medel and Lola re-enter Mr. Rodriguez's room. You tell him, "At this point, it seems most likely that you may either have some acid from your stomach that is irritating your esophagus, the tube that connects your mouth and stomach, or that you might have irritation from acid in your stomach, ibuprofen, or infection in your stomach, which may have caused an ulcer." Mr. Rodriguez appears startled at the word "ulcer," and he becomes visibly more worried as you finish your sentence. You take a moment to ask him, "It seems like something I've said made you nervous. Did it?" You reply, "I'm sorry, I didn't mean to upset you. While we want to carefully consider possible causes, we don't think your symptoms today represent a serious condition." You add, "Sometimes people may experience other symptoms that might indicate more serious disease." You review the alarm symptoms of potential complications warranting referral to a gastroenterologist with him, asking him to let you know right away if he experiences any of these symptoms. You also give him a  . You tell Mr. Rodriguez that a medication called omeprazole may help reduce or take away his pain and heal a possible …