His heartburn was way out of control, even on maximum doses of pantoprazole and ranitidine. It burned all the way up behind his breastbone and he could feel the choking quality of the sticky acidity deep in his throat. He hurt and coughed after eating, so hard that he would vomit and lose his breath. What he vomited was mostly mucous. “It’s like my esophagus is bubbling over”, he described it.
If he missed a dose of either medication, his symptoms worsened within an hour. “So the medications must be doing something, but nowhere near enough”, he told me.
A couple of years ago he had been turned down for an upper endoscopy because he also happened to have severe angina, and the gastroenterologist was concerned about his anesthesia risk.
“So I keep suffering”, he sighed.
He had the head of his bed elevated, and he didn’t eat spicy food or drink alcohol, but he did smoke. And he admitted to a “smokers cough”, every morning with some light colored phlegm.
I listened. Something didn’t fit. He talked too much about mucous.
“Would you be willing to try something?” I asked.
“Anything”, he answered.
I listened to his lungs and recorded his Peak Expiratory Flow, 300, moderately below normal.
“You have COPD”, I explained.
He raised his eyebrows.
“Chronic Bronchitis, one form of COPD, is defined as cough with phlegm more than two months out of the year. I’d like you to try an inhaler that reduces your phlegm production and improves your breathing.”
I left the room and went to get an inhaler from the sample closet. I logged it in the EMR and showed him how the device works and said, “use this once a day and see me back in two weeks. It will help your ’smokers cough’, but it may also do something for your heartburn. If not, we’ll really have to put our thinking caps on”.
Exactly two weeks later, after I knocked on the exam room door and entered, he rose from his chair with a big grin and stretched out his right hand.
“With that inhaler just once a day, my heartburn is completely gone.”
I checked his Peak Flow, 420.
“And your breathing is better, too”, I added.
“Yes, and my smokers cough.”
I sat down.
“All these years, all the doctors I’ve seen, and you just listened for a few minutes and…gave me an inhaler. Was it not GERD?”
I told him what I thought.
“You’ve got bad acid reflux, no question, but you also, obviously, have chronic bronchitis. So we’ve helped your breathing and dried up your bronchial secretions, which were very significant and very bothersome. Some of them probably went down your esophagus, even if you weren’t consciously swallowing them, and maybe caused some irritation.”
I took a deep breath and continued:
“But the inhaler I gave you is called an anticholinergic. It doesn’t just reduce secretions in your lungs. It is absorbed into the blood stream and can have anticholinergic effects elsewhere in the body. I once had a patient, an older man with an enlarged prostate, become unable to urinate and need his bladder catheterized because the inhaler affected his bladder’s ability to contract. We use anticholinergic pills to help the problems many women have with frequent urination. Medications with anticholinergic side effects, like amitriptyline, can also affect bowel contractions and cause constipation. But I’ve never seen that from an inhaler like the one I gave you.”
He seemed almost spellbound, and I continued:
“I really didn’t know if the inhaler would do much for your acid reflux, and I’ve never heard of it being used for that, but when I was young I had terrible heartburn from the hiatal hernia I didn’t even know I had back then. This was before the kinds of medicines you take were invented, before omeprazole, the Swedish forerunner to pantoprazole, and before ranitidine. The only medicine that existed for stomach acid was – an anticholinergic. I still remember, it was called “ULCOBAN” [probably for ’ulcer banned’?], and I also still remember how dry my mouth used to be when I took it. But it worked.
So, it was just a gut feeling, no pun intended, that there might be a double effect from the anticholinergic inhaler, less mucous in your lungs and less acid in your stomach. And we lucked out.”
I thought he’d never let go of my hand as he shook it on his way out.
.
I’ve been toying with this dilemma for a while: SOAP notes (Subjective, Objective, Assessment, Plan) are too long; APSO just jumbles the order, but the core items are still too far apart, with too much fluff in between. We need something better – aSOAP!
A Country Doctor Writes: 
