Chapter 20, Module 7; Heartburn and Indigestion

Question 1

Infants: Spitting up 3-5 times a day
Adults: Pain occurs after a meal and lasts a few minutes
No other symptoms

Answer 1

GER

Question 2

PHYSICAL FINDINGS OF GER?

Answer 2

NONE

Question 3

DIAGNOSTIC STUDIES FOR GER?

Answer 3

NONE

Question 4

Heartburn, pyrosis Possible extraesophageal symptoms, laryngitis, wheezing, cough Infants: Weight loss, arching of back, vomiting, irritability

Answer 4

GERD

Question 5

PHYSICAL FINDINGS OF GERD ARE?

Answer 5

None
Possible wheezing with asthma
Obesity
Growth chart change

Question 6

DIAGNOSTIC STUDIES FOR GERD?

Answer 6

Trial of antacids
Trial of PPI
pH monitoring
Endoscopy for refractory symptoms to rule out erosions

Question 7

Odynophagia, dysphagia, retrosternal pain; possible fever, nausea, and vomiting

Answer 7

Infective esophagitis

Question 8

PHYSICAL FINDING OF Infective esophagitis?

Answer 8

None

Possible fever

Question 9

DIAGNOSTIC STUDIES FOR Infective esophagitis?

Answer 9

Endoscopy: ulcerations, exudates

Question 10

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

Answer 10

AEE

Question 11

PHYSICAL FINDINGS ARE AEE?

Answer 11

None

Possible allergic rhinitis, atopic dermatitis

Question 12

DIAGNOSTIC STUDIES FOR AEE?

Answer 12

Endoscopy: linear furrowing and multiple rings

Question 13

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

Answer 13

Pill esophagitis

Question 14

PHYSICAL FINDINGS FOR Pill esophagitis?

Answer 14

NONE

Question 15

DIAGNOSTIC STUDIES FOR Pill esophagitis?

Answer 15

Endoscopy: focal lesion

Question 16

Burning retrosternal discomfort or pain Symptoms present for the last 3 mo

Answer 16

Functional heartburn

Question 17

PHYSICAL FINDINGS FOR Functional heartburn?

Answer 17

NONE

Question 18

DIAGNOSTIC STUDIES Functional heartburn ?

Answer 18

Endoscopy

Question 19

Pain in epigastrium or lower chest that worsens on reclining; relieved on standing Pain may be retrosternal with radiation down left arm

Answer 19

Hiatal hernia

Question 20

PHYSICAL FINDINGS FOR Hiatal hernia?

Answer 20

None
Large hernia may create dullness on percussion over the left lung base, absent breath sounds, or bowel sounds resent in the chest

Question 21

DIAGNOSTIC STUDIES Hiatal hernia?

Answer 21

UGI

Question 22

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

Answer 22

PUD

Question 23

PHYSICAL FINDINGS OF PUD?

Answer 23

NONE

Question 24

DIAGNOSTIC STUDIES PUD

Answer 24

Endoscopy: ulcers; H. pylori testing CBC if suspect anemia FOBT for bleeding

Question 25

Alarm  symptoms:  dysphagia  (solids or  liquids),  odynophagia,  anorexia, and  unintentional  weight  loss Repeated  exposure  to  irritants  such as  smoking,  alcohol History  of  Barrett  esophagus

Answer 25

Esophageal cancer

Question 26

PHYSICAL FINDINGS Esophageal cancer?

Answer 26

Advanced  disease:  cachexia, ipsilateral  Horner  syndrome (miosis,  ptosis,  absence  of sweating  on  ipsilateral  face and  neck),  supraclavicular adenopathy,  hoarseness, halitosis

Question 27

DIAGNOSTIC STUDIES Esophageal cancer?

Answer 27

Endoscopy

Question 28

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

Answer 28

Gastric  cancer

Question 29

PHYSICAL FINDINGS Gastric  cancer?

Answer 29

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

Question 30

DIAGNOSTIC STUDIES Gastric  cancer?

Answer 30

Endoscopy +  FOBT

Question 31

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

Answer 31

Gastritis

Question 32

PHYSICAL FINDINGS Gastritis?

Answer 32

Possible  epigastric  tenderness

Question 33

DIAGNOSTIC STUDIES Gastritis

Answer 33

Endoscopy  for  patients with  alarm  features  or persistent  symptoms Additional  workup  may include  testing  for H.  pylori CBC  if  anemia  suspected FOBT  for  bleeding

Question 34

Epigastric  pain  or  burning  with postprandial  fullness,  early satiation Symptoms  for  3-6  mo

Answer 34

Dyspepsia

Question 35

PHYSICAL FINDINGS Dyspepsia ?

Answer 35

Dyspepsia

Question 36

DIAGNOSTIC STUDIES Dyspepsia?

Answer 36

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

Question 37

Risk  factors:  excessive  amounts of  caffeine  or  alcohol,  smoking, steroids,  NSAIDs,  living  in  an  area with  high  prevalence  of  H.  pylori

Answer 37

Functional dyspepsia (nonulcer dyspepsia)

Question 38

PHYSICAL FINDINGS Functional dyspepsia (nonulcer dyspepsia)?

Answer 38

NONE

Question 39

DIAGNOSTIC STUDIES Functional dyspepsia (nonulcer dyspepsia)?

Answer 39

H.  pylori  testing Testing  for  structural disease,  negative findings

Question 40

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

Answer 40

Gas/gas entrapment

Question 41

PHYSICAL FINDINGS OF Gas/gas entrapment?

Answer 41

Possible  distended  abdomen with  hyperresonance  on percussion

Question 42

DIAGNOSTIC STUDIES OF Gas/gas entrapment?

Answer 42

NONE

Question 43

Severe,  oppressive,  constricting, retrosternal  discomfort  lasting longer  than  30  min Possible  prior  history  of  Ml  or angina

Answer 43

Acute  coronary insufficiency

Question 44

PHYSICAL FINDINGS OF Acute  coronary insufficiency?

Answer 44

Possible  abnormal  heart  sounds such  as  paradoxical  S2  during pain;  transient  S3  (ventricular gallop)  or  mitral  regurgitation murmur  at  the  apex;  S4  (atrial gallop)

Question 45

DIAGNOSTIC STUDIES OF Acute  coronary insufficiency?

Answer 45

ECG:  intermittent  ischemic changes  or  normal Cardiac  isoenzymes normal

Question 46

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

Answer 46

Stable  angina

Question 47

PHYSICAL FINDINGS OF Stable  angina?

Answer 47

Possible  diaphoresis  and shortness  of  breath Transient  S4  gallop  during  an episode  of  pain

Question 48

DIAGNOSTIC STUDIES OF Stable  angina?

Answer 48

ECG  during  an  episode of  pain;  ST  segment depression  and  T  wave inversions,  or  the  findings can  be  normal

Question 49

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

Answer 49

Ml

Question 50

PHYSICAL FINDINGS OF Ml?

Answer 50

Skin  pallor,  cool  diaphoretic  skin Hypertensive  or  hypotensive Possible  transient  paradoxical S2  or  abnormal  rhythms including  tachycardia  and bradycardia

Question 51

DIAGNOSTIC STUDIES OF Ml?

Answer 51

ECG:  ST  segment  elevations,  T  wave  inversions, and  Q  waves Cardiac  enzymes  elevated