. Explain which is the most likely diagnosis for the patient and why. Include
an explanation of unique characteristics of the disorder you identified as the primary diagnosis.
Then, explain a treatment and management plan for the patient, including appropriate dosages
for any recommended treatments. Finally, explain strategies for educating patients and families
on the treatment and management of the gastrointestinal disorder.
Case Study 2:
Victoria is a 15-year-old who complains of chronic sore throat and bad taste in her mouth. Her
height and weight are appropriate for age and she remains on the same growth trajectory since
infancy. Abdominal examination and chest examination are negative. History reveals frequent
burping and occasional feelings of regurgitating food. Diet history reveals she eats a balanced
diet, but her primary sources of fluids are coffee, tea, and carbonated drinks.
GASTROESOPHAGEAL REFLUX DISEASE
A female adolescent reports chronic sore throat accompanied by bad taste in her mouth. Her
growth trajectory has been consistent since birth and the body mass index is normal. Both
abdominal and chest examinations are normal. History taking reveals frequent burping and
regurgitating of food reported to be occasional. On further history taking, she reports that she
takes a balanced diet, but her common sources of fluids are coffee, tea and carbonated drinks.
The diagnosis for this patient is gastroesophageal reflux disease (GERD). This is characterized
by symptoms such as heartburn, regurgitating of food, sore throat that doesn’t go away for a
while and bad taste in the mouth among other signs (TeensHealth, 2015). Although occasional
regurgitation of food may be common to everyone, it is a classic sign of GERD especially when
it is not associated with nausea. WebMD (2015) defines gastroesophageal reflux as “the return of
the stomach’s contents back up into the esophagus”. WebMD further suggests carrying out a
special x-ray test known as barium-swallow radiograph that would help rule out other possible
Treatment and management
If GERD is left untreated, serious pathologic changes in the esophageal lining may occur which
may develop into more complicated disorders. For this mild case, early treatment would be
appropriate which would include Proton pump inhibitor (PPI) such as Omeprazole 20mg once a
day before meals for four weeks (PDRHealth, 2015) This would provide a more rapid symptom
control and better healing. The chronic sore throat and bad taste in her mouth would be
addressed by educating the patient some diet and lifestyle changes such as reducing or avoiding
fluids and foods containing caffeine and nicotine and carbonated snacks, taking smaller but
frequent meals and eating two to three hours before bedtime.
A patient presenting with the above symptoms would also be suffering from stomach ulcers
which would be due to bacteria H.Pylori. The bacteria increase the acid content in the stomach,
therefore presenting similar symptoms as GERD.
PDRHealth 2015; Physicians’
TeensHealth 2015, Gastroesophageal Reflux Disease.