Gastroesophageal Reflux Laurie A. Belknap, D.O., FAAFP Assistant Professor of Family Medicine

Instructions Articulate Module Review Content Complete Quiz Utilize Learning Resources Virtual Patient Click on the link to meet the patient. Obtain a Complete History Generate a list of appropriate Differential Diagnoses IHIS Learn Click on the link to access IHIS Learn. Locate your unique patient using middle initials, and review the Patient Chart Review Patient Data and Physical Findings Place Appropriate Orders Document the Patient Encounter including Patient Education Instructions Be sure to close your encounter when completed

Learning Objectives .Recognize common presenting symptoms and identify causes for gastroesophageal reflux in patients of all ages(GERD).( , , )  Generate a differential diagnosis for chest pain. ( ).  Identify Red Flag Warnings and “Don’t Miss” diagnoses in a patient with epigastric abdominal pain.( )  Become familiar with the age appropriate evaluation and initial management associated with epigastric abdominal pain. ( , )  Apply evidence based clinical guidelines and recognize treatment options for patients with GERD.( )  Describe patient education concepts that improve care for a patient with GERD.( )

Learning Resources  Clinical Guidelines for Family Physicians: Management of Pediatric Gastroesophageal Reflux Disease,Skolnik and Carcia, May 1, 2014, FAMILYPRACTICENEWS.com  The Patient History text, Chapter 34 Dyspepsia, pages  Medscape Reference, Gastroesophageal Reflux Disease  Gastrointestinal Motility Disorders in Children, Gastroenterology and Hepatol(NY), Jan 2014; 10(1):  Guidelines for the Management of Dyspepsia, American Journal of Gastroenterology,, ISSN , c.2005

PCMH Principles Enhance Access and ContinuityIdentify and Manage PopulationsPlan and Manage CareProvide Self Care Support and Community ResourcesTrack and Coordinate CareMeasure and Improve Performance

Presenting Signs and Symptoms, Adults and Children Heartburn Regurgitation Difficulty swallowing Frequent belching Persistent coughing Wheezing Recurrent hoarseness Sore throatNauseaSour Taste Poor Weight gain Irritability Feeding refusal ChokingArching back Sleep disturbances

Presenting Signs and Symptoms, Infants Poor Weight gain Irritability Feeding refusal ChokingArching back Sleep disturbances

Causes of GERD

Red Flag Warnings, Adults  Always consider the most serious problems that can present with a patient complaint of “heartburn.” CardiovascularPulmonaryMusculoskeletal Gastrointestinal Other

Red Flag Warnings, Adults and Children Bilious vomiting Hematochezia Abdominal distention Abdominal tenderness Associated Chronic Disease History Fever Lethargy Seizures Hepatosplenomegaly Heme positive stool Physical Exam

Red Flag Warnings, Infants Neurologic Impairment Esophageal Atresia Genetic Disorders, esp. CF Preterm Infants Bilious or bloody vomiting History Poor weight gain, “Failure to Thrive” Wheezing, Cough, Hoarseness Irritability, “Colic” Bulging fontanelle Micro/Macrocephaly Physical Exam

“Don’t Miss” Diagnoses UlcerFailure to thrive, Weight lossDental erosionsIschemic ColitisInfiltrative DiseaseErosive EsophagitisCancerBarrett’s Esophagus

Evaluation  History  Physical Examination  Lifestyle changes  Upper GI  Endoscopy (EGD)  Esophageal pH Monitoring  Esophageal Manometry

Management, Adults and Children Wait and See Dietary Changes, OTC antacids, H2 blockers, PPI Empiric Anti- secretory Therapy Full dose PPI Test and Treat for H Pylori Treat if +, and anti-secretory therapy EGD

Patient Education, Adults and Children OTC Medications, Antacids, H2RA, PPI’s Smoking cessation Weight loss Avoid overeating Avoid alcohol Avoid certain foods Avoid late night eating and lying down after eating

Management, Infants Modified feeding practices Thicken all feeds Keep upright after feeds Hydrolyzed protein formula Medications H2 Blockers PPI approved for infants>1 year Imaging UGI Endoscopy

Parent Education For Infants Monitor weight gain and growth Avoid environmental tobacco smoke Reduce the volume of feeds and increase frequency Thicken feeds with rice cereal Maternal dietary restriction of eggs and milk if breastfeeding Consider non-milk based formula if bottle feeding Keep infants upright or prone, left lateral position for sleeping

Summary Alarm Symptoms Diet and Feeding Past Medical History Lifestyle, Social History History Growth and Weight General Exam Respiratory Exam Abdominal Exam Physical Exam Feeding and Nutrition Positioning Weight Tobacco use Patient Education

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IHIS Instructions 1.You have now completed the articulate module associated with this activity, “Gastroesophageal Reflux.” If needed, please review basic IHIS navigation information including the creation and documentation of a patient encounter. You may access the IHIS Ambulatory Modules via the NetLearning site at mylearning.osumc.edu. Please be sure you are familiar with access to IHIS Learn before beginning. 2.Interview the patient “Jasmine XX Zhang” and obtain a complete history by clicking on the link below. 3.Access IHIS Learn by clicking on the link below and review your assigned patient chart “Jasmine XX Zhang”,” documenting Chief Complaint, Vital Signs, Allergies, Medication Documentation, History, and Progress Note in the appropriate sections. 4.Review and document the Physical Examination findings using the dot phrase “.EXAMJASMINEZHANG” in the Objective section of your progress note. 5. Review and document lab testing results using the dot phrase “.LABJASMINEZHANG.” 6.Review and document imaging results using the dot phrase “.IMAGEJASMINEZHANG.” 7.Create an assessment and differential diagnosis list based upon the findings of the History and Physical Examination, lab and imaging. List your diagnoses in the “Dx and Orders” section of the chart. 8. Place desired orders, and assign a diagnosis code to each one. You may sign your orders.“ 9.Create a plan in the Progress Note, documenting orders placed, medication ordered, patient education and follow up instructions given in the appropriate sections. Remember to include any plans you may have for the patient for routine preventive care and return appointment. 10.Enter “NCNC” and desired follow up for the patient in the LOS &Follow-up section. 11.Close the encounter by clicking on the appropriate tab at the bottom of the Navigation bar on the lower left column on the screen. INTERVIEW JASMINE ZHANG JASMINE ACCESS IHIS LEARN 12

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