Infant Regurgitation and Pediatric Gastroesophageal Reflux Disease.

Dear writer, i need a discussion reply to a fellow classmate clinical experience post for an FNP pediatric class clinic rotation. Please do not critique the actual paper but rather expand on her original points and or add opinion if needed. I will in addition attach the class book. student clinical postThis week the office continues busy, we continue providing care by telemedicine, a method that becomes new for us, but we are getting used to practicing because it’s acceptable and very comfortable for the patients and their families. They see it as the new trend and accessible from any place. My preceptor is a constructive professional who guides my day and teaches during clinical, who show me the necessary tools for my future practice, including literature. The case that got my attention this week was a teenage girl of 16 years old. Y.N 16-yer-old female with the consent of her mother seek primary medical attention because of vomiting. She has past medical history of GERD since she was a little child, apparently with periods of remission and exacerbation of the condition, treated with PPI and H2 Blockers like Ranitidine and Omeprazole, medications she states provide some relieve. Y.N complaints now of 3 days of post-prandial heartburn, nausea and vomiting associate with chest discomfort, denies fever, palpitation, or shortness of breath. She also denies hematemesis, melena, or rectal bleeding, there is no weight loss reported, and her current medications are not helping, and episodes and symptoms increased. Part of her medical history is hospitalization due to Asthma and GERD exacerbation. Y.N denies medication allergies, food intolerances, and surgeries. As per patient mother, Y.N immunizations are up to date; she has a very active life as a college fulltime student and working part-time in a sushi restaurant. Y. N has a healthy lifestyle, including a balanced diet and an appropriate exercise regimen. She denies smoking, illegal drug use, or alcohol consumption because she knows they may exacerbate her condition. She always avoids them to prevent hospitalizations, especially these days, with COVID 19 cases in all the hospitals. The patient and mother were asked about sleeping hours and Y. N’s response was that she has to study a lot, and resting time is less than usual. Then following the preceptor’s advice I proceed with patient assessment and system review, instructing patients to collect all necessary information and be able to indicate the best treatment option.Y.N assessment and review of the systems except for gastrointestinal symptoms were normal, with no history of cardiac problems, rheumatic fever, or heart murmurs. Patient Denies chest pain, palpitations, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, or edema. No cough, sputum, hemoptysis, or dyspnea. Denies having a recent episode of asthma exacerbation, bronchitis, pneumonia, or any other pulmonary condition. Patient report heartburn, changes in appetite during exacerbation periods, avoiding some food that increased symptoms; report nausea, and vomiting associate with chest pressure after eating. Y.N has bowel movements every day described by her as usual. The stools are brown and formed with no presence of blood, black or tarry stools. Denies pain or bleeding with defecation, also no changes in bowel habits or excessive passing gas. When reviewed e-chart, there is no history of jaundice, hepatitis, liver, or gallbladder conditions. Y.N is a well-nourished female teenager, also well-developed and groomed, active, cooperative, in no acute distress, her mother denies history of anemia or bleeding, but a CBC and CMP were ordered to be collected at home. To monitor Hb levels, a Chest XRay by mobile services to rule out Hiatal hernia due to patient chest pressure during vomiting episodes. (Levine MS), an Abdominal Ultrasound to evaluate liver and biliary tree, and referral to gastroenterologist consult for further evaluation and possible Upper GI Endoscopy to look for GERD complications.After reviewed all symptoms reported by the patient and her mother, a diagnosis of Gastroesophageal reflux disease without esophagitis is suspected due to the patient’s past medical history of GERD with multiples episodes of exacerbations evidence by patient current clinical condition presenting heartburn, nausea vomiting associate with chest pressure. As Differential Diagnosis, we can mention the Hernia Hiatal condition that can’t be ruled out totally until the CXR result because a worsening of GERD symptoms with poor response to treatment can suggest a possibility of the presence of Hiatal Hernia. Also, Achalasia conditions with the same symptoms as GERD with but with swallow difficulties, evidence by typical symptoms such as heartburn, chest pressure, nausea, and vomiting, as described by the patient. Cholelithiasis, for the presence of nausea and vomiting after eating, in this case, associated with abdominal pain. The treatment plan, in this case, includes the suggestion of lifestyle changes and medications.We recommend the patient to continue a balanced and healthy diet to avoid increased body weight, avoid alcohol, chocolate, citrus juice, and tomato-based products coffee and peppermint. She must avoid large and late meals, and wait at least 3 hours to go to sleep or lying down after a meal, and elevate the head of the bed. Pharmacological treatment includes discontinue current medications and prescribe new H2 receptor antagonists and Proton Pump Inhibitor, both very helpful in GERD treatment, helping 70-80 % of patients. We start the patient on Famotidine 20 mg PO every 12 hr for 6 weeks, and esomeprazole 20 mg take 1 tablet PO daily for 4 weeks; the parent was instructed to supervise therapy and adherence to medication regimen by the patient.Then, a follow-up visit was scheduled within 4 weeks to evaluate the response of new treatment, but we also advised both patient and parent that if symptoms persist or there is no response to treatment to call the office or visit the Emergency department in the nearest hospital for emergency evaluation.I think one of the most critical aspects of today’s practice is the application of technology by providers and patients to ensure adequate medical care, in which both parties actively interact and share information towards better lifestyles and health outcomes.References:Esposito, C., Escolino, M., Del Conte, F., Farina, A., Cortese, G., Iannazzone, M., … & Montupet, P. (2019). Antireflux Surgery for Gastroesophageal Reflux Disease (GERD). In ESPES Manual of Pediatric Minimally Invasive Surgery (pp. 185-190).Springer, Cham. Masud, F., & Valani, R. (2018). Gastroesophageal Reflux Disease (GERD). Essentials of Pediatric Emergency Medicine, 284.Singendonk, M. M., Tabbers, M. M., Benninga, M. A., & Langendam, M. W. (2018). Pediatric gastroesophageal reflux disease: Systematic review on prognosis and prognostic factors. Journal of pediatric gastroenterology and nutrition, 66(2), 239-243.Vandenplas, Y. (2017). Infant Regurgitation and Pediatric Gastroesophageal Reflux Disease. In Pediatric Neurogastroenterology (pp. 355-367). Springer, Cham.