Based on the patient’s subjective and objective assessment, Gastroesophageal Reflux Disease (GERD) and tonsillitis feature predominantly as the most probable causes of the symptoms. While a differential diagnosis points to the possibility of these two diseases, it is evident that tonsillitis can be ruled out from the case since there no signs of swollen tonsils or difficulties in swallowing (Weinberger & Fischer, 2014). Swelling of tonsils and pain are classical symptoms of tonsillitis but based on the subjective assessment findings, these symptoms are absent. As such, this GERD the primary cause of the symptoms and the most probable diagnosis for the 15-year-old.
Regurgitating food, sore throat, dry cough, frequent burping and heartburn are among the classical symptoms of GERD (Czinn & Blanchard, 2013). Coupled with the fact that patient takes a lot of acidic beverages such as coffee, carbonated drinks and tea, there is a high likelihood that the patient is suffering from GERD. Acidic foods and drinks are known to exacerbate GERD and definitely, this happens to be the case with this patient.
The care plan for this patient would include both pharmacological and non-pharmacological approaches (lifestyle modifications). For the pharmacological approach, the use of antacids as first line medication and proton pump inhibitors in the event that the symptoms persist would go a long way in the treatment of GERD (Katz, Gerson & Vela, 2013). However, management of GERD requires various lifestyle modifications, especially on diets. In this regard, it is important for the patient to reduce intake of acidic foods and drinks and eat smaller amounts of foods (Kavitt & Vaezi, 2016). This makes patient education on lifestyle modifications essential so as to equip her with the necessary self-efficacy and self-management skills. Among the strategies to use in this patient education is incorporating a parent or a guardian so as to help in obtaining the necessary foods and the overall management of the condition from a dietary approach. Use of illustrative diagrams alongside a take-home health brochure or pamphlet on GERD would also foster a better understanding of how to go about dietary modifications.
References
Czinn, S. J., & Blanchard, S. (2013). Gastroesophageal reflux disease in neonates and infants. Pediatric Drugs, 15(1), 19-27.
Katz, P. O., Gerson, L. B., & Vela, M. F. (2013). Guidelines for the diagnosis and management of gastroesophageal reflux disease. The American journal of gastroenterology, 108(3), 308.
Kavitt, R. T., & Vaezi, M. F. (2016). Gastroesophageal Reflux Disease.Practical Gastroenterology and Hepatology Board Review Toolkit, 69, 31.
Weinberger, M., & Fischer, A. (2014, March). Differential diagnosis of chronic cough in children. In Allergy and Asthma Proceedings (Vol. 35, No. 2, pp. 95-103). OceanSide Publications, Inc.
