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During a routine examination, a 65-year-old woman complains to her gynecologist that she has not been sleeping well for the past 5 or 6 months because of a sensation of pressure and burning in the middle of her chest. Further questioning reveals that she also feels the pressure and burning intermittently during the day; however, it is not induced by exercise and is relieved by antacids. The patient's blood pressure is 135/82 mm Hg, her pulse is 96/min and regular, and her temperature is 37.0ºC (98.6ºF). Her heart sounds are normal, and her lungs are clear. Palpation of her abdomen reveals no abnormalities. Which of the following is the most appropriate first step in the management of this patient?
A: Refer her to a psychologist
B: Prescribe cisapride
C: Prescribe ranitidine, cimetidine, nizatidine, or famotidine
D: Order an electrocardiogram (EKG)
E: Prescribe antibiotics to control gastric Helicobacter pylori
F: Prescribe omeprazole, lansoprazole, rabeprazole, esomeprozole, or pantoprazole
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my ans C H2 blockers are the 1st line drugs in mx of GERD with mild to moderate symptoms
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d. order for an EKG.
rule out any underlying hesrt diseases, age and htn are the risk factors.
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The differential diagnosis of this patient resides among gastroesophageal reflux disorder (GERD), peptic ulcer with associated reflux disease, an esophageal motility disorder, panic disorder, and some type of myocardial disease. GERD is suggested by pain that is not induced by exercise and is relieved by antacids. However, a myocardial disorder (e.g., atypical angina) is still a possibility and could be life threatening. Therefore, an electrocardiogram (EKG) should be performed immediately (choice D).
Referral to a psychologist (choice A) would be a proper course of action for panic disorder, which is often associated with chest discomfort. However, the absence of other symptoms makes this an unlikely diagnosis. Cisapride (choice B) decreases reflux activity by acting as a prokinetic motility agent that increases the strength of esophageal peristalsis, raises the lower esophageal sphincter pressure, and increases the rate of gastric emptying; however, not only should potential cardiac problems be ruled out first, but cisapride was voluntarily withdrawn from the market in 2000 because of potential side effects. The histamine blockers mentioned in choice C or the proton pump inhibitor listed in choice F lower acid secretion. However, after heart problems are ruled out, the first line of treatment recommended by the American College of Gastroenterology is a series of lifestyle changes. Controlling gastric Helicobacter pylori infection (choice E) is part of the standard treatment used to cure peptic ulcers, not GERD.
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Eventhough my dx is GERD ,I'd order EKG first to rule out the dangerous thing
