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Gastro-Oesophageal Reflux Disease (GORD)

Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓

 

Doctor Instruction:


You are a doctor working in the emergency department. Your next patient is a 42-year-old woman (Alexander Great) presenting with abdominal pain. Please take a history and perform an appropriate examination.



 

Patient History:


Alexander Great, a 42-year-old retired hairdresser.


This morning at around 3am, you woke up from having tummy pain. Described as a sharp/burning sensation that started at the bottom chest centrally and radiated up to the neck. It is intermittent and lasts for a few seconds. Pain score: 5/10. You are known to have angina, and so you took a GTN spray, but it didn't help. You feel a bit nauseous but no vomiting; you had some retching (and a bad taste in the back of the throat). Pain tends to be worsened or triggered when you try to go back to bed and lay flat.


If asked specifically, you remember having quite a big family meal when your friend came to visit the night before.


No weight loss. No tiredness. No erosion in teeth. No bad-smelling mouth. No lump in the throat. No bloating. No nocturnal cough. No hoarse voice. Bowels working normally with no bloody stool. No breathing difficulty. No dysphagia. No LOC. No dizziness. No palpitation. No obvious chest pain.


Ideas, Concerns, Expectations:

  • You are not sure what is going on. You are worried that you had a heart attack and may die because of this since it is quite close to the chest. You want to be seen by a cardiologist and have some medications to help prevent having this pain again. You want to live!


Past Medical History:

  • Hypertension

  • Stable angina - well-controlled

  • Obesity

  • Chronic Lower Back Pain


Drug History:

  • Amlodipine, GTN spray PRN, Atovastatin, ibuprofen

  • NKDA


Family History:

  • Type 2 DM (Dad, age 44)

  • Colon Cancer (Dad, age 65)


Social History:

  • Smoker – 10 cigarettes/day for 20 + years

  • Drink a small glass of gin and tonic every night

  • Hairdresser

  • Drink 2 cups of coffee a day.


 

Examination Findings:

  • The patient is alert + comfortable at rest, with no signs of breathing difficulties.

  • No clinical signs of anaemia.

  • Some mild discomfort palpating the epigastric region.

  • Abdominal examination is otherwise normal.

  • PR exam is normal - no melena or blood in the stool.


 

Differentials:

  1. GORD

  2. Gastritis

  3. Peptic ulcer

  4. Hiatus Hernia

  5. Oesophagitis / Oesophageal spasm

  6. To rule out cardiovascular causes: Stable Angina / ACS / AAA


 

Investigations:


Bedside:

  • Observations

  • ECG – rule out cardiac cause


Bloods:

  • FBC, CRP, U&Es, LFTs, Bone Profile, Troponin (if suspecting cardiac cause)


Imaging:

  • CXR/AXR (?Hiatus hernia)


Special Tests:

  • Consider serology/ urea breath test/ stool antigen, rapid urease test (H-pylori testing - ensure not taken PPI 2 weeks prior to testing)

  • Barium swallow - assess dynamics, assess motility disorder, assess for hiatus hernia

  • Oesophageal pH monitoring / Manometry - Assess for motility & regurgitative Disorders

  • Consider OGD (Savary-Miller grading/ Los Angeles Classification) - allows direct visualisation and biopsy for histology.


 

Data Interpretation:

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