Infants: Spitting up 3-5 times a day
Adults: Pain occurs after a meal and lasts a few minutes
No other symptoms
PHYSICAL FINDINGS OF GER?
DIAGNOSTIC STUDIES FOR GER?
Heartburn, pyrosis Possible extraesophageal symptoms, laryngitis, wheezing, cough Infants: Weight loss, arching of back, vomiting, irritability
PHYSICAL FINDINGS OF GERD ARE?
Possible wheezing with asthma
Growth chart change
DIAGNOSTIC STUDIES FOR GERD?
Trial of antacids
Trial of PPI
Endoscopy for refractory symptoms to rule out erosions
Odynophagia, dysphagia, retrosternal pain; possible fever, nausea, and vomiting
PHYSICAL FINDING OF Infective esophagitis?
DIAGNOSTIC STUDIES FOR Infective esophagitis?
Endoscopy: ulcerations, exudates
Young children and adolescents: Dyspepsia, heartburn, vomiting, irritability, food refusal, early satiation
Adults: Heartburn, epigastric or chest pain, dysphagia, and food impaction
Personal or family history of allergic disorders
PHYSICAL FINDINGS ARE AEE?
Possible allergic rhinitis, atopic dermatitis
DIAGNOSTIC STUDIES FOR AEE?
Endoscopy: linear furrowing and multiple rings
Medication history: tetracycline, potassium chloride, ferrous sulfate, NSAIDs, and bisphosphonates Takes medication at bedtime with insufficient water, and/or lying down directly after taking Acute discomfort followed by progressive retrosternal pain
PHYSICAL FINDINGS FOR Pill esophagitis?
DIAGNOSTIC STUDIES FOR Pill esophagitis?
Endoscopy: focal lesion
Burning retrosternal discomfort or pain Symptoms present for the last 3 mo
PHYSICAL FINDINGS FOR Functional heartburn?
DIAGNOSTIC STUDIES Functional heartburn ?
Pain in epigastrium or lower chest that worsens on reclining; relieved on standing Pain may be retrosternal with radiation down left arm
PHYSICAL FINDINGS FOR Hiatal hernia?
Large hernia may create dullness on percussion over the left lung base, absent breath sounds, or bowel sounds resent in the chest
DIAGNOSTIC STUDIES Hiatal hernia?
Episodic gnawing or epigastric pain usually 2-5 hr after meals or on empty stomach Nighttime awakening because of pain; symptom relief with food intake, antacids, or antisecretory agents Fullness, bloating, early satiation, vomiting, indigestion, loss of appetite, heartburn, hematemesis, back pain, and unexplained weight loss Medication history: NSAIDs, aspirin, high dose corticosteroids, bisphosphonates, mycophenolate, potassium chloride, and fluorouracil Children may present with generalized abdominal pain Older patients may be asymptomatic, but may also present with nonspecific complaints including confusion, restlessness, abdominal distention, and falls
PHYSICAL FINDINGS OF PUD?
DIAGNOSTIC STUDIES PUD
Endoscopy: ulcers; H. pylori testing CBC if suspect anemia FOBT for bleeding
Alarm symptoms: dysphagia (solids or liquids), odynophagia, anorexia, and unintentional weight loss Repeated exposure to irritants such as smoking, alcohol History of Barrett esophagus
PHYSICAL FINDINGS Esophageal cancer?
Advanced disease: cachexia, ipsilateral Horner syndrome (miosis, ptosis, absence of sweating on ipsilateral face and neck), supraclavicular adenopathy, hoarseness, halitosis
DIAGNOSTIC STUDIES Esophageal cancer?
Dyspepsia unrelieved by antacids, epigastric discomfort, usually lessened by fasting, and exacerbated by food intake and early satiation Alarm symptoms of dysphagia, anorexia, and weight loss
PHYSICAL FINDINGS Gastric cancer?
Epigastric swelling or mass may be present on palpation Advanced disease: cachexia, palpable left supraclavicular (Virchow) node, palpable hard lymph node in umbilicus A hard, nodular liver indicates metastatic disease May be pale from anemia Ascites, pleural effusions may indicate metastasis
DIAGNOSTIC STUDIES Gastric cancer?
Endoscopy + FOBT
Dyspepsia with abdominal pain, indigestion, heartburn, and epigastric discomfort that is worse after eating, loss of appetite, sense of fullness, nausea, occasional vomiting, burning or gnawing feeling in the stomach between meals or at night Excessive alcohol use, chronic vomiting, stress, or the ingestion of aspirin, NSAIDs, or steroid. Bile gastritis can occur after partial gastrectomy, truncal vagotomy and pyloroplasty for peptic ulcer reflux, or cholecystectomy Bile reflux can cause severe epigastric abdominal pain, accompanied by bilious vomiting, and weight loss
PHYSICAL FINDINGS Gastritis?
Possible epigastric tenderness
DIAGNOSTIC STUDIES Gastritis
Endoscopy for patients with alarm features or persistent symptoms
Additional workup may include testing for H. pylori CBC if anemia suspected
FOBT for bleeding
Epigastric pain or burning with postprandial fullness, early satiation Symptoms for 3-6 mo
PHYSICAL FINDINGS Dyspepsia ?
DIAGNOSTIC STUDIES Dyspepsia?
Endoscopy: for patients 55 yr and older, those with weight loss, progressive dysphagia, recurrent vomiting, evidence of Gl bleeding, or family history of cancer, new-onset dyspepsia H. pylori testing: patients 55 yr and younger with¬ out alarm features
Risk factors: excessive amounts of caffeine or alcohol, smoking, steroids, NSAIDs, living in an area with high prevalence of H. pylori
Functional dyspepsia (nonulcer dyspepsia)
PHYSICAL FINDINGS Functional dyspepsia (nonulcer dyspepsia)?
DIAGNOSTIC STUDIES Functional dyspepsia (nonulcer dyspepsia)?
H. pylori testing Testing for structural disease, negative findings
Abdominal discomfort, vague feelings of indigestion; abdominal bloating, belching, chest pain Ingestion of flatulogenic foods, Gl stasis, constipation, malabsorption, air swallowing (aerophagia), hurried eating or drinking, smoking or chewing gum, poorly fitting dentures, or dry mouth from anxiety or anticholinergics Pain worsens by bending over or wearing tight garments and is relieved by passage of flatus
PHYSICAL FINDINGS OF Gas/gas entrapment?
Possible distended abdomen with hyperresonance on percussion
DIAGNOSTIC STUDIES OF Gas/gas entrapment?
Severe, oppressive, constricting, retrosternal discomfort lasting longer than 30 min Possible prior history of Ml or angina
Acute coronary insufficiency
PHYSICAL FINDINGS OF Acute coronary insufficiency?
Possible abnormal heart sounds such as paradoxical S2 during pain; transient S3 (ventricular gallop) or mitral regurgitation murmur at the apex; S4 (atrial gallop)
DIAGNOSTIC STUDIES OF Acute coronary insufficiency?
ECG: intermittent ischemic changes or normal Cardiac isoenzymes normal
Chest pain typically described as substernal chest pressure or heaviness, radiating to the left shoulder and arm, neck, or jaw Onset brought on and exacerbated by exercise and stress; typically lasts 2 to 10 min Alleviated with rest and/or nitroglycerin
PHYSICAL FINDINGS OF Stable angina?
Possible diaphoresis and shortness of breath Transient S4 gallop during an episode of pain
DIAGNOSTIC STUDIES OF Stable angina?
ECG during an episode of pain; ST segment depression and T wave inversions, or the findings can be normal
Sudden onset of pain at rest Persistent, often severe, deep, central chest pain; and may radiate to the throat or neck, across both sides of the chest to the shoulder, and/or down the medial aspect of either or both arms Nitroglycerin does not relieve the pain Possible sense of impending doom Risk factors: Men 45 yr and older; women 55 yr and older; cigarette smoker; hyperlipidemia; hypertension; diabetes; obesity; history of CAD; family history of CAD
PHYSICAL FINDINGS OF Ml?
Skin pallor, cool diaphoretic skin Hypertensive or hypotensive Possible transient paradoxical S2 or abnormal rhythms including tachycardia and bradycardia
DIAGNOSTIC STUDIES OF Ml?
ECG: ST segment elevations, T wave inversions, and Q waves Cardiac enzymes elevated