Symptoms of GERD include heartburn (burning sensation in the retrosternal area) commonly postprandial, regurgitation gastric contents into mouth, dysphagia from esophageal inﬂammation, and chest pain that can be confused as angina. Dysphagia that is progressive is concerning for Barrett’s metaplasia or adenocarcinoma and merits an endoscopic evaluation (61).
Treatment of GERD is multifaceted with lifestyle modification and use of antacids and over-the-counter H2 receptor antagonists or proton pump inhibitors (PPI). Lifestyle modifications include smoking cessation, avoidance of eating late in the evening, avoidance of being supine after eating, weight loss, avoidance of tight clothing, and restriction of alcohol use. Dietary modifications are helpful but should not be draconian, which will ensure noncompliance. Key foods to try to minimize are fatty foods, chocolate, peppermint, and excessive alcohol. The patient can monitor her own symptoms for the foods that are most problematic for her.
Medications that reduce acid secretions are best and include H2 blockers or proton pump inhibitors. They do not prevent the reﬂux but decrease the damage done by the acid when reﬂuxed. Medication needs to be titrated to the severity of the symptoms. H2 blockers commonly work well for acute pain but in placebo-controlled studies in chronic cases without resolution of heartburn after the common 6-week course, it was found that patients on PPI do better. Maintenance therapy is recommended for patients who have rapid recurrence of symptoms (in less than 2–3 months) after they stop their medication. Otherwise patients can be managed with episodic treatments. The linkage of Helicobacter pylori infections and GERD is poorly understood but seems to be mediated through increased gastric acid secretion. Treatment can initially worsen GERD and may not improve it (62). Benefits and risks should be discussed with the patient prior to testing and treating for H. pylori. The management of GERD during pregnancy is similar to the treatment in the nonpregnant patient.
Carpal tunnel syndrome (CTS) is the cluster of symptoms brought on by compression in the carpal tunnel of the median nerve. These are paresthesia, pain, and weakness. The symptoms are commonly worse at night and may wake the patient from sleep. It is thought women may be more likely to present with complaints of CTS because of their small wrists, repetitive motion injury at work (typing, holding telephone, and reading), and pregnancy with increased edema. The pain and paresthesia can be located in the wrist or hand or can be in the forearm. The weakness may cause a patient to have difficulty opening jars, lifting a plate, turning a doorknob, or holding a glass.
A detailed history is very diagnostic but the use of a couple simple tests can help to confirm it (63). The most common one is the Phalen maneuver, in which the patient ﬂexes her palms at the wrist as close to 90 degrees as possible. Then with the dorsal portion of the hands touching and the arms parallel to the ﬂoor, the patient presses the ﬂexed hands against each other for approximately 1 minute. This should reproduce her symptoms along the median nerve. The Tinel test involves percussion over the top of the carpal tunnel where the median nerve travels. A positive test is when the percussion reproduces the pain and paresthesia. Additional testing such as nerve conduction studies should be reserved for patients who do not respond to conservative management or have significant muscle weakness.
Treatment involves lifestyle modification to decrease repetitive motion injuries or prolonged marked ﬂexion at the wrist. A carpal tunnel brace can be very helpful in maintaining adequate extension at the wrist, thereby “opening” the tunnel and reducing compression on the medial nerve. Only if these strategies do not work is a surgical intervention indicated.
Mitral Valve Prolapse Syndrome, Dysautonomia, and Postural Orthostatic Tachycardia Syndrome