What is the diagnosis and treatment plan for a patient presenting with gastroesophageal reflux disease (GERD) symptoms, including heartburn, and tongue discomfort, who has been taking over-the-counter omeprazole (Prilosec) and recently discontinued Vraylar (cariprazine), with a past medical history of menopause?

Summary

The patient presents with multiple concerns, primarily reflux symptoms and tongue discomfort. The reflux symptoms started about a month ago, with heartburn worsening at night, and were partially controlled with an increase in omeprazole dosage. The tongue discomfort is described as aching and intermittent, moving around different areas of the tongue, with some relief from chewing sugar-free gum. Additional symptoms include occasional dizziness upon waking, hot flashes at night attributed to menopause, and recent discontinuation of Vraylar (cariprazine) due to insurance issues.

Differential Diagnoses for Tongue Pain and GERD

• Single Most Likely Diagnosis

  • For tongue pain: Burning Mouth Syndrome (BMS) - Given the description of intermittent, aching pain that moves around the tongue, and the absence of visible lesions or changes in taste, BMS is a plausible diagnosis. The relief from chewing sugar-free gum, possibly due to increased saliva production, also supports this.
  • For GERD: Gastroesophageal Reflux Disease (GERD) - The patient's symptoms of heartburn, particularly at night, and the partial response to omeprazole, strongly suggest GERD.

• Other Likely Diagnoses

  • For tongue pain:
    • Nutritional Deficiencies (e.g., vitamin B12, iron, or zinc deficiency) - These can cause oral symptoms, including tongue discomfort, and the patient's diet and multivitamin use could be relevant.
    • Oral Habits or Stress - The intermittent nature of the pain and relief with distraction (chewing gum) could suggest a component of oral habits or stress-related etiology.
  • For GERD:
    • Diet and Lifestyle Factors - Although the patient denies specific food triggers, dietary factors and lifestyle (e.g., eating close to bedtime, despite the patient's denial) could still contribute to GERD symptoms.
    • Hormonal Changes - Menopause could potentially influence gastrointestinal motility or sensitivity, contributing to GERD symptoms.

• Do Not Miss Diagnoses

  • For tongue pain:
    • Oral Cancer - Although the patient has seen a periodontist and denies lesions or bleeding, oral cancer must be considered, especially with persistent or unexplained oral pain.
    • Neuropathic Pain - Conditions like trigeminal neuralgia could cause intermittent, severe pain, although the description here doesn't fully align with typical neuropathic pain patterns.
  • For GERD:
    • Esophageal Cancer or Stricture - Unintentional weight loss, dysphagia, or persistent symptoms despite treatment could suggest more serious conditions, although the patient denies weight loss and hematemesis.
    • Cardiac Ischemia - Atypical chest pain or discomfort can sometimes be confused with GERD, and it's crucial to consider cardiac causes, especially in patients with risk factors.

• Rare Diagnoses

  • For tongue pain:
    • Geographic Tongue - Characterized by lesions, which the patient denies, but could be considered if the tongue appearance changes.
    • Glossodynia - A condition of unknown cause, characterized by a burning sensation of the tongue, which might be considered if other diagnoses are ruled out.
  • For GERD:
    • Eosinophilic Esophagitis - An immune system disorder that could cause difficulty swallowing, food impaction, or heartburn, more common in patients with atopic conditions or allergies.
    • Zollinger-Ellison Syndrome - A rare disorder characterized by excessive gastric acid production, which could cause severe, refractory GERD symptoms.