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THE PT.
GENERAL DATA
HISTORY
OF PRESENT ILLNESS
Admissio
n
7 DAYS
PTA pain
(+) Epigastric
HISTORY
OF PRESENT ILLNESS
Admissio
n
7 DAYS
PTA
Consult
at a private
clinic
Dx: ARD + UTI
Meds Given:
CEFIXIME BID (dosage
unrecalled)
OMEPRAZOLE 20mg/tab OD
HISTORY
OF PRESENT ILLNESS
6 DAYS 2 DAYS
PTA
7 DAYS
PTA pain
(+) Epigastric
(+) Dysuria
(+) Consult
Dx: ARD + UTI
(-) associated
S/Sx
Admissio
n
HISTORY
OF PRESENT ILLNESS
6 DAYS 2 DAYS
PTA
7 DAYS
PTA pain
(+) Epigastric
(+) Dysuria
(+) Consult
Dx: ARD + UTI
(-) associated
S/Sx
Admissio
n
HISTORY
OF PRESENT ILLNESS
6 DAYS 2 DAYS
PTA
7 DAYS
PTA pain
(+) Epigastric
(+) Dysuria
(+) Consult
Dx: ARD + UTI
(-) associated
S/Sx
Admissio
n
1 DAY PTA
(+) continuous epigastric pain after missing a
meal.
HISTORY
OF PRESENT ILLNESS
(-) associated
S/Sx
Medications
continued
6 DAYS 2 DAYS
PTA
7 DAYS
PTA pain
(+) Epigastric
(+) Dysuria
(+) Consult
Dx: ARD + UTI
(-) associated
S/Sx
1 DAY PTA
(+) Epigastric pain
(+) Associated
DOB and
weakness
Admissio
n
FEW HRS
PTA Pain
(+) Epigastric
Same
characteristics
Rated 8-9/10
HISTORY
FEEDING HISTORY
HISTORY
Weight= 46 kg
Height= 1.57m
BMI: 18.66 = Normal
Physical growth:
No reported delays in growth
and Development.
No observed impairments
HISTORY
HISTORY
HISTORY
SUICIDE
No grave problems
that would warrant
suicidal ideologies
HISTORY
IMMUNIZATION STATUS
2001
2004
BETHANY
HOSPITAL
LA UNION
- Innocent Heart
Murmurs
- Anemia
D/C WELL
SLU-HSH
- Pneumonia
- Benign Febrile
Convulsions
D/C WELL
2007
SLU-HSH
- Pneumonia
D/C WELL
HISTORY
FAMILY DISEASES
REVIEW
OF 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,
PHYS.EX
PERTINENT FINDINGS
General Survey:
Awake, conscious, coherent, afebrile, not in cardiorespiratory
distress.
No signs of Dehydration
Chest/Lungs and Heart:
SCWE (-)retractions, (-) lagging , clear breath sounds,
PHYS.EX
PERTINENT FINDINGS
Abdomen:
Flat, non-distended
(+) normoactive bowel sounds
(+) tympanitic on all four quadrants
Soft
(+) tenderness on epigastric area upon deep
palpation,
(-) masses palpated
(-) organomegaly
IMPRESSION
DIAGNOSIS OF THE PT
HISTORY (S)
Previous Dx:
Acid related
disorder
Under
gastric
medications
History of:
(+) Epig Pain (89/10)
Burning in nature
Radiating to chest
Precipitated by an
empty stomach
Aggravated by
activity
Relieved by food
intake and
medication
(-) Febrile episode
PHYS.EX (O)
Flat, non-distended
Normoactive bowel
sounds
(-) Visible Mass and
Pulsation
(-) Palpated Mass
Direct tenderness on
Epigastric area
(-) pathologic
gallbladder/
appendyceal signs
IMPRESSION
DIAGNOSIS OF THE PT
DAY10
Initial Impression: ARD
Gastroesophageal Reflux
Disease (GERD)
PLAN
DIAGNOSTICS
URINALYSIS
Unremarkable Results
PLAN
DIAGNOSTICS
CBCP
Normochromic, normocytic
RBCs
Normal: Hgb, Hct, Platelets,
WBC (neutrophilic
predominance)
*Essentially normal
PLAN
DIAGNOSTICS
DISCUSSION
1. History
2.
3.
4.
5.
Physical Examination
Laboratory Tests
Imaging Studies
Empiric Interventions
Chronic Abdominal Pain in Childhood: Diagnosis and Management
ALAN M. LAKE, M.D., Johns Hopkins University School of Medicine, Baltimore,
Maryland
Am Fam Physician.
PHYSIO
REVIEW
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 factor
Chief 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.
PHYSIO
REVIEW
The principal stimulants for acid secretion are:
a) Histamine
major paracrine stimulator of acid secretion
b)
Gastrin
c) Acetylcholine
directly stimulates acid secretion by binding to
muscarinic (M3)
receptors
PHYSIO
REVIEW
The principal stimulants for acid secretion are:
a) Histamine
major paracrine stimulator of acid secretion
b)
Gastrin
c) Acetylcholine
directly stimulates acid secretion by binding to
muscarinic (M3)
receptors
GERD
GERD
DISCUSSION
GERD
DISCUSSION
GERD
CLINICAL PRESENTATION
DISCUSSION
GERD
CLINICAL PRESENTATION
DISCUSSION
GERD
DIAGNOSIS
DISCUSSION
GERD
DIAGNOSIS
DISCUSSION
GERD
DIAGNOSIS
DISCUSSION
GERD
MANAGEMENT
DISCUSSION
Treatment
Parental education, guidance, and support
Lifestyle changes
Pharmacologic therapies
Surgical 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).
GERD
MANAGEMENT
DISCUSSION
Conservative measures:
Providing small, frequent feeds thickened
with cereal
Upright positioning after feeding
Elevating the head of the bed
Prone positioning (infants >6 months)
GERD
MANAGEMENT
DISCUSSION
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
GERD
MANAGEMENT
DISCUSSION
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
GERD
MANAGEMENT
DISCUSSION
GERD
MANAGEMENT
DISCUSSION
GERD
MANAGEMENT
DISCUSSION
GERD
MANAGEMENT
DISCUSSION
PHARMACOLOGY
Antacids :
aluminum hydroxide, magnesium hydroxide
Histamine H2 antagonists :
nizatidine, cimetidine, ranitidine, famotidine
GERD
MANAGEMENT
DISCUSSION
Histamine-2receptor antagonists
(H2RAs) produce relief of symptoms and
mucosal healing.(A)
Proton pump inhibitors (PPIs) are
superior to H2RAs in relieving symptoms
Pediatric gastroesophageal reflux clinical practice
and healing esophagitis.(A)
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).
GERD
MANAGEMENT
DISCUSSION
SURGICAL INTERVENTION
gastrostomy 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
GERD
MANAGEMENT
DISCUSSION
SURGICAL INTERVENTION
gastrostomy 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
GERD
MANAGEMENT
DISCUSSION