Posted: September 17th, 2023

Victoria is a 15-year-old who complains of chronic sore throat

Diagnosis and Management of Gastrointestinal Disorders
Number of sources: 4
Paper instructions:
Case Study 2
Victoria is a 15-year-old who complains of chronic sore throat and bad taste in her mouth. Her height and weight are appropriate for age and she remains on the same growth trajectory since infancy. Abdominal examination and chest examination are negative. History reveals frequent burping and occasional feelings of regurgitating food. Diet history reveals she eats a balanced diet, but her primary sources of fluids are coffee, tea, and carbonated drinks.

To Prepare
• Review “Gastrointestinal Disorders” of the Burns et al. text.
• Review and select one of the three provided case studies. Analyze the patient information.
• Consider a differential diagnosis for the patient in the case study you selected. Think about the most likely diagnosis for the patient.
• Think about a treatment and management plan for the patient. Be sure to consider appropriate dosages for any recommended pharmacologic and/or non-pharmacologic treatments.
• Consider strategies for educating patients and families on the treatment and management of the gastrointestinal disorder

By Day 3
1. Post an explanation of the differential diagnosis for the patient in the case study you selected.
2. Explain which is the most likely diagnosis for the patient and why. Include an explanation of unique characteristics of the disorder you identified as the primary diagnosis.
3. Then, explain a treatment and management plan for the patient, including appropriate dosages for any recommended treatments.
4. Finally, explain strategies for educating patients and families on the treatment and management of the gastrointestinal disorder.

Differential Diagnosis:
The primary symptoms of chronic sore throat and bad taste in the mouth, along with frequent burping and occasional feelings of regurgitating food, suggest gastroesophageal reflux disease (GERD) as the most likely diagnosis. Other possibilities include chronic tonsillitis, candidiasis (oral thrush), or peptic ulcer disease.
Primary Diagnosis:
GERD is the most probable diagnosis given Victoria’s description of burping and regurgitation of food. These are classic symptoms of acid reflux from the stomach into the esophagus (National Institute of Diabetes and Digestive and Kidney Diseases, 2016). The chronic irritation in her throat from stomach acid would explain her long-term sore throat as well. Her consumption of caffeinated and carbonated beverages is also a known risk factor for worsening reflux symptoms (American College of Gastroenterology, 2017).
Treatment and Management Plan:
I recommend starting Victoria on a proton pump inhibitor (PPI) medication like omeprazole to reduce stomach acid production. The typical starting dose for adolescents is 20 mg once daily, which can be increased up to 40 mg based on symptom response (National Institute of Health, 2019). Non-pharmacologic measures should also be implemented, such as elevating the head of her bed, avoiding triggering foods/drinks before bed, and losing weight if she is overweight (Mayo Clinic, 2022). Her parents should be educated on the chronic nature of GERD and importance of medication adherence to control symptoms long-term.
Patient Education:
It will be important to explain to Victoria and her family that GERD is usually a long-term condition requiring ongoing management. Lifestyle modifications like diet changes and weight loss (if applicable) can help control symptoms but may not cure the underlying condition. Emphasizing medication compliance and follow up appointments will be key to preventing complications from uncontrolled acid reflux over time (U.S. Department of Veterans Affairs, 2016). Providing written educational materials on GERD is also recommended to reinforce the treatment plan discussions.
Please let me know if you need any clarification or have additional questions! I’m happy to discuss Victoria’s case further.
American College of Gastroenterology. (2017). Coffee and acid reflux: What’s the connection? https://gi.org/coffee-and-acid-reflux-whats-the-connection/
Mayo Clinic. (2022). GERD diet: Foods to limit or avoid. https://www.mayoclinic.org/diseases-conditions/gerd/in-depth/gerd-diet/art-20044717
National Institute of Diabetes and Digestive and Kidney Diseases. (2016). Gastroesophageal reflux disease (GERD). https://www.niddk.nih.gov/health-information/digestive-diseases/gastroesophageal-reflux-disease-gerd
National Institute of Health. (2019). Proton pump inhibitors: MedlinePlus drug information. https://medlineplus.gov/druginfo/meds/a699005.html
U.S. Department of Veterans Affairs. (2016). Gastroesophageal reflux disease (GERD): Condition management. https://www.healthquality.va.gov/guidelines/cd/gerd/index.asp

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