Gastrointestinal Disorder Case Study #3

MP a 56-year-old general contractor who is admitted to your telemetry unit directly from his internist’s office with a diagnosis of chest pain. On report, you are informed that he has an intermittent 2-month h/o of chest tightness with substernal burning that radiates through to the mid-back intermittently, in a stabbing fashion. Symptoms occur after a large meal; with heavy lifting at the construction site; and in the middle of the night when he awakens from sleep with coughing, SOB, and a foul, bitter taste in his mouth. Recently he has developed N, without emesis, worse in the morning or after skipping meals. He c/o “heartburn” 3 or 4 times a day. He takes a couple Rolaids or Tums. He keeps a bottle at home, at the office, and in his truck. VS at his physician’s office were 130/80 lying, 120/72 standing, 100, 20, 98.6˚F. Pulse Ox is 92% on room air. A 12-lead EKG showed normal sinus rhythm with a rare premature ventricular contraction (PVC).

1. What are some common causes of chest pain?

MP indicates that usually the chest pain is relieved with his antacids, but this time they had no effect. A “GI cocktail” consisting of Mylanta and viscous lidocaine given at the physician’s office briefly helped decrease symptoms.

2. What was the purpose and giving MP the Mylanta and lidocaine? How do these drugs work?

MP has smoked 1 ppd for the past 35 years, drinks 2 or 3 beers on most nights, and has noticed a 20 pound weight gain over the past 10 years. He feels “so tired and old now.” MP has dark circles under his eyes and c/o daytime fatigue. His wife is even sleeping in another bedroom because he is snoring so loudly. He also reinjured his lower back a month ago at work lifting a pile of boards, so his physician prescribed Ibuprofen 800 mg bid or tid for 4 weeks.

Gastrointestinal Disorders – Case Study #3 3. Change the pounds that he gained into kg.

4. Which factors in MP’s life are likely contributing to his chest pain and nausea? Explain how.

5. What is a hiatal hernia, and what is its role in GERD?

MP’s 12-lead EKG was normal, and the first set of cardiac enzymes were normal. CBC showed an elevated WBC (6,000), Hgb 15, Hct 47%, platelets 220,000. Chem profile revealed Na+ 140, K+ 3.8, BUN 20, Creatinine 1.0. The CXR showed no abnormalities. MP begins to c/o N; as you hand him a bath basin, he promptly vomits coffee-ground emesis with specks of bright red blood. VS remain stable.

6. What did MP vomit and why?

You inform your charge nurse. The gastroenterologist gives several orders and states he will be there in 45 minutes. The orders are as follows:

NPO status for emergent EGD STAT CBC

O2 by NC Type and Cross (T&C) for 2 units of PRBC’s and hold Start a Protonix drip at 8 mg/hr Insert an NGT and start a gastric lavage with water or saline Insert 2 large bore IV’s and start NS (normal saline) @ 100 ml/hr

7. Explain the rationale for each of the preceding orders .

8. Making two columns list drugs that will decrease HCL acid production/output (what is their classification) and drugs that will neutralize HCl acid/raise the gastric pH (what is their classification)?

Gastrointestinal Disorders – Case Study #3