Dyspepsia in Pregnancy

Emily Johnson

32 years, Female

Role-play cases simulate real clinical practice to guide how candidates respond to clinical scenarios and real life practice.

Patient Information:

Name: Emily Johnson
Age: 32 years
Gender: Female

Presenting Complaint:
Emily presents to the GP practice with complaints of acid reflux.

Opening Statement: Hi, Doctor. I've been having terrible acid reflux lately, especially at night. I had it during my pregnancy two years ago and then again a couple of months ago. Now that I am pregnant again, it's really bothering me, and I need something for it.

History of Presenting Complaint:

Onset: Initially experienced acid reflux during pregnancy 2 years ago.
Recurrence: Episodes occurred again 2 months ago.
Symptoms: Experiencing heartburn and discomfort after meals, particularly at night.
Aggravating Factors: Late-night meals, alcohol, spicy foods.
Alleviating Factors: Gaviscon, patient seeks medication for relief.

History Only if Asked

Pregnancy: Currently 20 weeks pregnant, pregnancy has been ok, it was planned, had nausea and vomiting which has now stopped. Has registered for ANC, has her pregnancy pack, has the details of midwife who is very helpful and has discussed vitamins, foods to eat and avoid, prescription certificate, MATB1.
Pregnancy has been fine, no discharge or bleeding, no abnormal tummy pain. Has not felt baby kicking
Dyspesia symptoms worse at night or when lying down.
No fever, weight loss or night sweats.
No blood in stools, no tummy lumps or swelling, no change in bowel habits

Lifestyle and Social History:

Occupation: Works in marketing, often has late-night projects.
Home: Married, has a daughter 2 years old, partner is aware of pregnancy, works in another city but has been supportive. Your mum lives close by and has been supportive, but your symptoms make you tired from poor sleep.
Diet: Frequently eats late at night, enjoys spicy foods and alcohol.
Smoking Status: Smoker, 1 stick daily, you have tried to quit, you know it has bad effect but feel 1 stick wont be bad.
Caffeine Intake: Regular coffee drinker.
Previous Medical History: Has never tested for dyspepsia
Medication History: Over the counter Gaviscon which has not helped
Allergies: None known.

Patient Ideas, Concerns & Expectations:

Ideas: Think it is same dyspepsia, symptoms are the same.
Concerns: Struggling with tiredness because you havent slept well, and having to take care of your daughter Maddy.
Expectations: Want medication.

How to React: You will prefer a prescription over lifestyle modifications, but will be co-operative with the doctor.

You are a doctor in your routine clinic, ready to begin your day of consultations. A patient has been booked to see you,

Name: Emily Johnson

Age: 32 years

Past Medical History: No significant medical history (Nil)

Medication History:

• Cerazette as directed

• No known drug allergies (NKDA)

Clinical Notes: No additional notes.

Investigation Results: No investigations conducted.

There are several key issues to address:
1. Accurate Diagnosis

Ensure correct diagnosis: Differentiating between simple acid reflux and other potential gastrointestinal issues.
Assessing for red flags: Even though there are no red flags mentioned, confirming the absence of serious symptoms like weight loss, vomiting, dysphagia, or gastrointestinal bleeding is essential.

2. Comprehensive History Taking

History of present illness: Detailed history of symptoms, their onset, duration, and aggravating and alleviating factors.
Previous history: Understanding her previous experiences with acid reflux during pregnancy and recent episodes.
Lifestyle factors: Identifying and discussing lifestyle factors that contribute to her symptoms, such as diet, alcohol intake, smoking, and caffeine consumption.
Medication history: Ensuring no contraindications or previous adverse reactions to medications prescribed.

3. Patient Education

Explanation of condition: Educating Emily about GERD and its common causes, especially in the context of her lifestyle and diet.
Importance of lifestyle modifications: Emphasizing how lifestyle changes can significantly impact symptom control and overall health.
Realistic expectations: Setting realistic expectations about the role of medication and the necessity of lifestyle changes.

4. Management Plan

Pharmacological treatment: Prescribing an appropriate PPI (e.g., omeprazole) and providing clear instructions on its use.
Lifestyle modifications: Discussing and strongly encouraging dietary changes, smoking cessation, reducing alcohol and caffeine intake, and avoiding late-night meals.
Follow-up plan: Scheduling a follow-up appointment to assess the effectiveness of the treatment and make necessary adjustments.

5. Addressing Patient Concerns and Preferences

Medication preference: Acknowledging Emily's preference for medication but reiterating the importance of lifestyle changes.
Empathy and support: Showing empathy for her situation and providing support for making difficult lifestyle adjustments.

6. Long-Term Management and Monitoring

Monitoring response: Regularly monitoring her response to treatment and making adjustments as needed.
Preventing recurrence: Providing advice on maintaining lifestyle changes to prevent future episodes.

7. Risk Factor Modification

Smoking cessation: Strongly advising Emily to quit smoking and providing resources to help with cessation.
Alcohol reduction: Discussing the impact of alcohol on GERD and encouraging reduction or elimination.

8. Addressing Pregnancy-Related Concerns

Safety of medications: Reassuring Emily about the safety of PPIs during pregnancy, as per current guidelines.
Monitoring: Regular monitoring of both her and her baby's health throughout the treatment.

By addressing these key issues, the GP can effectively manage Emily's case, ensuring both immediate relief of symptoms and long-term prevention of GERD.

These are the key issues in this clinical scenario.

Marking Scheme for Dyspepsia In Pregnancy.

Data Gathering and Diagnosis

Marking Criteria:
Clear Pass: Comprehensive history taken, all relevant factors assessed, no red flags missed.
Pass: Adequate history taken, most relevant factors assessed, no major red flags missed.
Fail: Incomplete history, missing key factors or potential red flags.
Clear Fail: Poor history taking, missing significant details, or red flags.

Phrases to Use:

"Can you describe the discomfort you feel after meals?"
"When did you first start experiencing these symptoms?"
"Have you noticed any patterns or triggers for your symptoms?"

Key Areas to Cover:

Initial onset during pregnancy and recent episodes.
Symptoms, aggravating factors, and any alleviating factors.
Absence of red flags (weight loss, vomiting, difficulty swallowing).

Lifestyle Factors:
Phrases to Use:
"Can you tell me about your typical eating schedule, especially late at night?"
"How many cigarettes do you smoke daily?"
"How much coffee do you drink?"
"How does your work at the restaurant affect your eating habits?"

Key Areas to Cover:
Eating habits, smoking, caffeine intake, work and stress levels.

Marking Criteria:
Clear Pass: Detailed lifestyle and social history taken, identifying all contributing factors.
Pass: Adequate lifestyle and social history taken, identifying most contributing factors.
Fail: Incomplete lifestyle and social history, missing key factors.
Clear Fail: Poor lifestyle and social history, missing significant contributing factors.

Clinical Management and Medical Complexity
Pharmacological Treatment:
Prescribing Medication: Important to let mum know the safety of omeprazole in pregnancy.
Phrases to Use:
"I'll prescribe omeprazole, which should help reduce the stomach acid causing your symptoms."
"Take this once daily before meals."

Key Areas to Cover:
Appropriate medication prescription with clear instructions.

Lifestyle Modifications:
Reinforcing Lifestyle Changes:
Phrases to Use:
"It's important to avoid late-night meals and reduce spicy foods and alcohol."
"Quitting smoking can significantly improve your symptoms and overall health."
"Try to limit your coffee intake as caffeine can worsen reflux."

Key Areas to Cover
Dietary changes, smoking cessation, caffeine reduction.

Follow-Up Plan:
Scheduling Follow-Up:
Phrases to Use:
"Let's arrange a follow-up in four weeks to see how you're responding to the treatment."
"If you experience any severe symptoms, such as vomiting or difficulty swallowing, please contact us immediately."

Key Areas to Cover:
Appropriate follow-up and safety netting

Interpersonal Skills / Relating to Others
Demonstrating Empathy:
Phrases to Use:
"I understand how uncomfortable this must be for you, especially with your busy schedule."
"It's tough managing these symptoms, but we're here to help you find relief."
"With the right treatment and some lifestyle adjustments, you should start feeling better soon."

Key Areas to Cover:
Showing empathy, acknowledging concerns, providing reassurance.

Communication Skills:
Phrases to Use:
"Heartburn is a common symptom of acid reflux, which we can manage effectively."
"Making a few changes to your eating habits can make a big difference."
"Feel free to share any other concerns or symptoms you might have."

Key Areas to Cover:Clear, non-medical language, explaining importance of addressing lifestyle, encouraging openness

Building Trust and Rapport:
Phrases to Use:
"I hear that you're worried about the pain after meals. Let's find a solution together."
"It's completely understandable to want quick relief, especially with your lifestyle."
"Your input is important in deciding the best way forward. How do you feel about the plan we've discussed?"

Key Areas to Cover:
Active listening, validating feelings, patient-centered approach.

Approaching Pregnancy Case in SCA

Holistic: The woman as a whole.
General approach: manage clinical situation and the pregnancy
Demonstrate clinical and cultural awareness about impact of pregnancy on home, finances and career.
Follow the consultation steps.
Ask about the pregnancy; number, order, previous pregnancy, LMP, was it difficult getting pregnant?
Ask about planned, accepted – do not be too quick to give congratulation without checking if appropriate. How does she feel about being pregnant?
Red flags; PV bleeding and discharge, Abd pain, fetalmovement if preg > 20 weeks + appropriate clinical red flag for case.
Past Medical History: Think DM, Epilepsy – folic acid requirement, complications in pregnancy.
Contraception and cervical smear
Partner– Where? Supportive? How do they feel about the pregnancy?
Finances and career (Impact, PSO)
ANC – Healthy Start Questions (https://www.healthystart.nhs.uk )