solved

Patient: Ms. Raj 60 year old Indonesian Female
I am experiencing heartburn after meals, especially after dinner, and every night when I lie down. Spicy food causes severe burning in my chest, nausea, and regurgitation.
Patient Hx: Ms. Raj also has a history of asthma and osteoporosis, and six months earlier, she fractured her hip following a fall.
Physical Examination Results:
Vital signs: T 98.4; RR 16; P 78; BP 118/64.
General: Alert and oriented and in no apparent distress.
Lungs: Clear to auscultation and percussion.
Neck: No palpable masses. Thyroid normal to palpation.
Heart: RRR without murmur or rub.
Abdomen: Soft. Bowel sounds heard in all 4 quadrants. Nontender throughout. No CVA tenderness. No masses and no hepatomegaly. No bruits heard.
Extremities: Distal pulses normal. No edema.
All Lab Work is NORMAL
DIAGNOSIS AND NEXT STEPS:
Based on the additional information you have gathered; you diagnose Ms. Raj with gastroesophageal reflux disease (GERD).
1. What are your next steps?
2. Considering her comorbid conditions of asthma and osteoporosis, what additional information should you obtain?
3. Based on Ms. Raj’s diagnosis and medical history, what would you advise as effective pharmacologic treatment options for managing her GERD?
4. What nonpharmacologic treatment options might be beneficial?
5. What education will you provide for Ms. Raj?
6. Are there specific monitoring parameters that would be appropriate for this patient relative to the therapy that you prescribe?

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