NGN Case Study: Gastrointestinal GI Patients—Sherpath Adaptive Quiz (EAQ)

NGN Case Study: Gastrointestinal

A 46-year-old female patient presents to the healthcare provider with the report of a burning sensation in her chest once or twice a week. The patient shares that the sensation usually occurs while she is lying down at night and lasts approximately 20 minutes. The patient expressed that she has taken calcium carbonate antacid (TUMS), and it has been effective. The electrocardiogram (ECG) displays no irregularities. A friend of the patient recommended that the patient keep a daily log of what food is consumed and when the burning sensation occurs, and the patient brought the log in for review.

• low Sheet
• Orders
• Imaging Studies

1035

• Avoid foods that contain acid
• Take over-the-counter (OTC) calcium carbonate (TUMS) as directed on the box as needed

1020 ECG results

• Rhythm: Normal sinus
• Rate: 80 bpm (reference range: 60-100 bpm)
• P waves: Upright and regular
• PR interval: 0.16 sec (reference range: 0.12-0.20 sec), 1 P for each QRS
• QRS: 0.8 sec (reference range: 0.4-0.12 sec)

done

That’s right!

Rationale:

Antacids are a medication often used for heartburn (reflux) and are available OTC. Antacids work by raising the pH level in the stomach lumen to neutralize the acid effects. They have a very short duration of 30 to 60 minutes and often cause constipation or diarrhea depending on the specific antacid. Antacids may decrease the effectiveness of quinolone antibiotics if taken at the same time and need to be taken at intervals to avoid patient harm. Similarly, H2 blockers are often found OTC and are used to treat reflux, however, typically a more severe reflux. H2 blockers work in the parietal cells in the lining of the stomach to inhibit histamine and prevent acid production. Older adults taking H2 blockers should be monitored because certain H2 medications can cause disorientation.

A 47-year-old construction foreman presents to the healthcare provider with reports of intermittent pain in his chest and a burning sensation in the substernal area that radiates to his back. The patient notices that the symptoms often occur after eating a large meal or while sleeping at night. The patient shares that he occasionally wakes up with a burning sensation, a cough, shortness of breath, and a foul taste in his mouth. He has taken calcium carbonate (TUMS) but states that TUMS do not work like they used to and that he often must take more to have relief of symptoms.

Patient History

• Meniscectomy
• Hammertoe
• Arthritis

The patient does not take any regularly scheduled medications, although he will occasionally take nonsteroidal anti-inflammatory drugs (NSAIDs) for arthritic pain.

Vital Signs:

• Temperature: 98.6^o F (37^o C)
• Pulse: 98 beats/min
• Respirations: 20 breaths/min
• Blood pressure: 130/64 mm Hg
• SpO₂: 98% on room air

Omeprazole 20 mg once a day by mouth.

• Log foods and symptoms each day for 1 week.

ECG

• Rhythm: Normal sinus
• Rate: 100 bpm (reference range: 60-100 bpm)
• P waves: Upright and regular
• PR interval: 0.16 sec (reference range: 0.12-0.20 sec), 1 P for each QRS
• QRS: 0.8 sec (reference range: 0.4-0.12 sec)

one

That’s right!

Rationale:

Gastroesophageal reflux disease (GERD) presents with burning in the chest (substernal area), which often radiates to the mid-back and often occurs after consumption of specific foods, after large meals, or when lying down. The reflux of gastric acid into the esophagus and mouth often causes coughing, shortness of breath, and a foul taste in the mouth. Proton pump inhibitors (PPIs) are often used to treat GERD. PPIs work by inhibiting the acid production and release of acid in the parietal cells. The use of PPIs puts patients at increased risk of hypomagnesemia by decreasing magnesium absorption levels in the intestines. The use of PPIs also puts patients at risk of community-acquired pneumonia related to a disturbance in the normal flora of the upper gastrointestinal system. The LPN would monitor serum magnesium levels for patients taking PPIs. The LPN would also reinforce patient education to notify their healthcare provider of muscle cramps, tremors, or seizures.

The patient does not report any self-induced vomiting (commonly associated with bulimia). The ECG shows normal sinus rhythm so the LPN would not be concerned about atrial fibrillation. There is not chart information that indicates any signs of mouth cancer.

PPIs such as omeprazole should be taken prior to meals to enhance the effectiveness of the medication. PPIs do not lead to hypersensitivity to the sun or excessive bleeding should a cut occur. INR levels, monthly WBCs, and daily glucose levels are not needed.

A 68-year-old man presents to the clinic with discomfort in the chest/abdomen and recent weight loss. The patient reports having heartburn for approximately 3 months, which is exacerbated by drinking coffee and alcohol as well as eating foods with high acid content. The patient shares that antacids have been helpful in minimizing the symptoms approximately 60% of the time. After stepping on the scale when clothes seemed to fit more loosely, the patient realized a 10-lb weight loss in 3 months. The patient also expresses concern that recent stools have been dark, almost black in color.

Patient history reveals:

• Diabetes type 1
• Osteoarthritis
• Hypertension
• Recent history of deep vein thrombosis (DVT; 1 month ago)
• History of a myocardial infarction (MI) 5 years ago

Current medications:

• Metformin for diabetes
• Nonsteroidal anti-inflammatory drugs (NSAIDs) taken daily for osteoarthritis
• Warfarin for DVT
• Daily Aspirin related to the history of MI

Vital Signs :

• Temperature: 98.7^o F (37.1^o C)
• Pulse: 99 beats/min
• Respiration: 21 breaths/min
• Blood pressure: 135/85 mm Hg

0900 Fecal occult blood test

• Positive reference range: Negative

0935 Urea breath test

• Positive reference range: Negative

1030

1135

• Upper digestive system endoscopy
• Upper gastrointestinal series (barium swallow and x-rays)

1630

• Famotidine 20 mg PO twice a day for 4 weeks

done

That’s right!

Rationale:

Peptic ulcer disease (PUD) can be concluded based on the symptoms of heartburn exacerbated with certain foods, weight loss, and dark stools. The use of aspirin and NSAIDs daily puts the patient at risk for PUD. Laboratory findings of a positive urea breath study indicate that the patient likely has Helicobacter pylori, which also increases the patient’s risk for PUD. A positive fecal occult blood test and low hemoglobin and hematocrit indicate the patient is losing blood in the digestive tract. The combination of these signs and symptoms does not lead to the conclusion of sepsis or a hiatal hernia.

Famotidine is an H2 blocker that is used to help treat PUD. H2 blockers often increase the levels of other drugs, which is of significant concern when therapeutic drug levels need to be maintained. Warfarin levels may be affected by H2 blockers and should be monitored closely. H2 blockers are not likely to affect blood pressure or glucose levels.