can you help me respond to this discussion post using high level references from the last 5 years?

46-year-old male complains of chest pain described as pain in his midchest for the past couple of months that has progressively worsened over the last couple of weeks. He states it is exacerbated when he goes to bed at night or eats a large meal. He has been eating out a lot more over the past couple of months because he has been traveling a lot for work. He denies any nausea or vomiting. He has been taking OTC Tums for the past few weeks, but he has to take 10-12 a day and only gets minimal relief. He denies any unusual weight gain or loss. Physical exam reveals an obese, Caucasian male with mild epigastric tenderness. No hepatosplenomegaly. Bowel sounds normoactive in all four quadrants. Provide the most likely diagnosis based on the HPI and PE. In addition, provide your interpretation of the cues found in the assessment. List at least 3 possible differential diagnoses and justify your rationale. Develop therapeutic plan options based on quality, evidence-based clinical guidelines.

The three differential diagnoses I came to based on the patients HPI and PI are:

Differential Diagnoses:

• Differential Diagnoses #1 (Primary): Gastroesophageal Reflux Disease (GERD). Based on the patient's complaints of mid-chest pain that worsens at night or after eating a large meal, Katz et al. (2022) state that the most common symptoms are chest pain that radiates up the neck or regurgitation, but not all symptoms are the same in every person. A GERD diagnosis is based on symptom manifestation and is typically treated empirically. "The consensus definition of GERD is a disease with symptoms or complaints resulting from regurgitation of stomach contents into the throat, hypopharynx, larynx, or lung. GERD symptoms vary in their timingdaytime, nighttime, when upright, when supine, or post-prandial" (Fashner, 2020). Some other symptoms that people often think are caused by GERD but can also be mimicked byother disorders are cough, laryngitis, chest discomfort, dyspepsia, epigastric pain, nausea, bloating, and belching. It is essential to follow up on other possible causes. Due to getting mild relief from taking Tums, it indicates that the relief from Tums is due to calming down the acid activity in the stomach. The issue has been ongoing for several months, so Tums is no longer effective at controlling the symptoms of GERD. His PE is unremarkable, which can rule out other possible conditions.
• Differential Diagnoses #2 (Possible): Peptic Ulcer Disease (PUD)- Malik et al. (2023) report that the signs and symptoms of peptic ulcer disease can be different depending on where the disease is and how old the person is. The timing of their symptoms with meals can help tell the difference between gastric and duodenal ulcers. People with duodenal ulcers often have pain at night. People with gastric outlet obstruction usually say they have had a history of bloating or fullness in their stomachs. Some common indications and symptoms are: pain in the upper abdomen, bloating, feeling full, nausea and vomiting, weight loss or gain, hematemesis, and melena. The patient does not complain of symptoms more indicative of PUD, no weight loss or weight gain, nor does he notice any blood in his stool, decreasing the likelihood of PUD. It is essential to rule out PUD as it can lead to more serious emergent conditions.

• Differential Diagnoses #3 (not likely): Angina- "commonly present with angina, which patients usually describe as pain, pressure, tightness, or heaviness in the chest, with potential radiation to the jaw or left arm. It may be accompanied by shortness of breath, diaphoresis, nausea, or any combination of the above" (Hermiz & Sedhai, 2024). They further explain that patients presenting with angina may appear asymptomatic, but seem anxious, or they could be clutching their chest. Typically, tachycardia and tachypnea are observed. The patient has not presented with any of these symptoms making this diagnosis less likely.

Therapeutic Plan (Based on Guidelines):

• Initiate high-dose Proton Pump Inhibitors (PPIs), e.g., omeprazole 40 mg once daily before breakfast, for at least 8 weeks to reduce acid secretion and promote healing (Fashner, 2020).
• Lifestyle modifications: weight loss, diet improvements (avoid fatty, spicy foods, large meals, late-night eating), and smoking cessation if applicable.
• Patient education on GERD triggers and symptom monitoring.
• Re-evaluate symptom control after 8 weeks; escalate therapy if symptoms persist.
• Consider further testing (e.g., endoscopy) if symptoms persist or complications arise.

References

Fashner, Julia (2020) "Gastroesophageal Reflux Disease: A General Overview,"HCA Healthcare Journal of Medicine: Vol. 1: Iss. 4, Article 3. DOI: 10.36518/2689-0216.1042

Hermiz C, Sedhai YR. Angina. [Updated 2023 Jun 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-.Available from: https://www.ncbi.nlm.nih.gov/books/NBK557672/

Katz, Philip O. MD, MACG1; Dunbar, Kerry B. MD, PhD2,3; Schnoll-Sussman, Felice H. MD, FACG1; Greer, Katarina B. MD, MS, FACG4; Yadlapati, Rena MD, MSHS5; Spechler, Stuart Jon MD, FACG6,7. ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. The American Journal of Gastroenterology 117(1):p 27-56, January 2022. | DOI: 10.14309/ajg.0000000000001538

Malik TF, Gnanapandithan K, Singh K. Peptic Ulcer Disease. [Updated 2023 Jun 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-.Available from: https://www.ncbi.nlm.nih.gov/books/NBK534792/

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