Case Study: Acute Gastroesophageal Reflux Disease (GERD)
Patient Information:
….
Name: Laura Martinez
Age: 35 years
Gender: Female
Occupation: Teacher
Medical History: Laura has a history of occasional heartburn and GERD symptoms,
Presenting Complaint: taura presents to the dinic weh complaints of severe chest pain andi
burning sensation behind the sternum for the past two days. She describes the pain as a sharp.
sour-tasting fluid into her mouth and occasional difficulty swallowing. She denies any associated
symptoms such as fever, cough, or abdominal pain.
Physical Examination:
Vital Signs: BP 120/80 mmkg. HR 70 bpm, RR 16/min, Temp 98.4′ (36.9°C)
Chest Examination: No abnormal findings on auscultation, no signs of respiratory
distress
Abdominal Examination: Soft and non-tender, no organomegaly
Other Findings: No signs of anemia or jaundice
Investigations:
1. Upper Endoscopy: Shows evidence of esophageal mucosal injury (erosive esophagitis)
with mucosal breaks and inflammation, indicative of GERD.
2. Esophageal pH Monitoring: Confirms increased acid exposure in the distal esophagus,
consistent with GERD.
Diagnosis: Acute Gastroesophageal Reflux Disease (GERD) with erosive esophagitis
Management: Laura is advised on lifestyle modifications, including avoiding trigger foods (e g.
spicy, fatty foods), eating smaller meals, and avoiding lying down after meals. She is prescribed a
proton purap inmonor they for so weeks to suppless bests add secretion and promoth
healing of esophageol mucosa. Antacids are provided for immediate relief of symptoms as
needed.
Questions for Medical Students:
1. What are the typical symptoms of GERD, and how is it differentiated from other causes
2. Describe the endoscopic findings seen in erosive esophagitis.
3. Discuss the pathophysiology of GERD and factors contributing to its development.
4. Outline the pharmacological and non-pharmacological management strategies for GERD,
including the role of Ppis, antacids, and ifestyle modifications.
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