46-year-old male complains of chest pain described as pain in his midchest for the past couple of months that

has
progressively worsened over the last couple of weeks. He states it has worsened when he is going to bed at night
or when he eats a large meal. He has been eating out a lot more over the past couple of months because he has
been traveling a lot for work. He denies any nausea or vomiting. He has been taking OTC Tums for the past few
weeks, but he has to take 10-12 a day and only gets minimal relief. He denies any unusual weight gain or loss.
Physical exam reveals an obese, Caucasian male with mild epigastric tenderness. No hepatosplenomegaly. Bowel
sounds normoactive in all four quadrants. Provide the most likely diagnosis based on the HPI and PE. In addition,
provide your interpretation of the cues found in the assessment. List at least 3 possible differential diagnoses and
justify your rationale. Develop therapeutic plan options based on quality, evidence-based clinical guidelines.

After reviewing the history of present illness and physical assessment of this 46-year-old

Caucasian male patient the most likely diagnosis would be gastroesophageal reflux disease

(GERD). Gastroesophageal reflux is when stomach acids come up and enter into the esophagus.

Gastroesophageal reflux is very common in many individuals however it because a disease when

symptoms begin, or esophageal injury is noted.

According to Cash & Glass (2017) “GERD is relaxation or incompetence of the lower

esophagus persisting beyond the newborn period. Relaxation of the lower esophageal sphincter

(LES) allows reflux of gastric acid and pepsin into the distal esophagus. Heartburn occurs when

reverse peristaltic waves cause regurgitation of acidic stomach contents into the esophagus.

Anatomical abnormalities, such as a hiatal hernia, predispose persons to GERD. Improper diet

and nervous tension are also precipitating factors.”

The patient is at high risk for GERD due to obesity, eating large meals, and eating out a

lot. He has been exhibiting the signs and symptoms for GERD such as sternal chest pain over the

past coupe of months that has progressively worsened, the pain worsens when he lies down, or

eats a large meal. He has tried TUMS to relief the pain however only experiencing minimal relief

after taking 10 -12 a day. Patients denies nausea and vomiting. Physical examination reveals

bowel sounds present normoactive in all four quadrants, mild epigastric tenderness, and no

hepatosplenomegaly (Kahrilas, 2020).

 Three differential diagnosis would include GERD, myocardial infarction, and gallbladder

disease. With complaints of sternal chest pain, it is important to rule out myocardial infarction or

chest pain related to a more benign cause. One of the most common reasons for noncardiac chest

pain is gastroesophageal disorders such as GERD (Cash & Glass, 2017).

A 12 lead ECG, CBC, CMP, and cardiac enzymes will be ordered to rule out myocardial

infarction. Once the myocardial infarction has been ruled out the diagnosis of GERD could be

made, and treatment plan would be started (Cash & Glass, 2017).

Therapeutic plan would include lifestyle changes, changes to diet, weight loss plan,

smoking cessation if patient is a smoker, avoid eating before bedtime, avoid alcohol

consumption, avoiding medications that can irritate the stomach, and avoid strain on the

abdomen. If symptoms persisted with lifestyle changes, I would have patient return for

reevaluation and start omeprazole 20mg every morning for 14 days and then reevaluate

(Kahrilas, 2020).

Cash, J., & Glass, C. (2020). Family Practice Guidelines (4th ed.). NEW YORK: SPRINGER

Publishing.

Kahrilas, P. (2020, April 1). Medical management of gastroesophageal reflux disease in adults.

In Grover, S. (Ed.), UpToDate. Retrieved September 23, 2020 from

https://www.uptodate.com/contents/medical-management-of-gastroesophageal-reflux-

disease-in-adults