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Discuss this patient’s likely diagnosis. Provide literature support for your choice.
The patient’s symptoms of persistent burning in the chest and upper abdomen that worsen when she lies down after meals and a sour taste in the mouth in the morning are indicative of gastroesophageal reflux disease (GERD). GERD is a condition whereby reflux of acid or bile salts occurs from the stomach to the esophagus resulting in the burning sensation that the patient experienced, (McCance et al., 2018).
Describe the pathophysiology of this disorder.
Under normal circumstances when food and acid reflux into the esophagus due to relaxation of the lower esophageal sphincter, peristalsis will help return most of the refluxed substance back to the stomach. However, in incidences where the patient has delayed gastric emptying, transient lower esophageal sphincter relaxation, impaired tissue resistance, decreased salivation, or impaired esophageal acid clearance the risk of reflux will increase. Here, when the patient experiences reflux, less of the acidic contents will be drained back to the stomach and remains in the esophagus or sometimes travels up to the throat leaving a burning sensation in its wake. The prolonged exposure of the esophageal mucosa to the reflux acid can cause injury and inflammation.
Discuss a plan of care for this patient. Be sure to include any cultural factors affecting this patient’s plan of care.
Proton pump inhibitors should be prescribed to heal the esophagitis and control the patient’s symptoms. She should be referred to a nutritionist to identify the foods that trigger her symptoms and the changes that she needs to make. Mrs. Taub admits that in her culture, hot and spicy food is common, which may be worsening her symptoms.
What is the anticipated prognosis for this patient? What lifestyle factors might alter her short- and long-term outcomes?
The patient should stop smoking as it is a risk factor that makes them more susceptible to reflux. Mrs. Taub should maintain an exercise routine to ensure her BMI remains within the normal range to avoid worsening of the symptoms. She should also elevate her head from the bed and avoid wearing tight clothing to help alleviate the symptoms. She should cease taking benzodiazepines for her insomnia as they exacerbate her GERD symptoms.

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