M.R. is 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 history 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, shortness of breath (SOB), and a foul, bitter taste in his mouth. Recently he has developed nausea, without emesis, worse in the morning or after skipping meals. He complains of “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. Vital signs (VS) at his physician’s office were 130/80 lying, 120/72 standing, 100, 20, 98.6° F, SaO2 92% on room air. A 12-lead ECG showed normal sinus rhythm with a rare premature ventricular contraction (PVC).
- What are some common causes of chest pain?
The most common causes of chest pain include angina, panic attacks, muscle strains, gallstones, acid reflux symptoms, and esophageal spasms (MedlinePlus, 2013).
- What mnemonic can you use to help you better evaluate his pain?
Onset: When and how did the pain begin?
Provocation: Is there any action that increases the level of pain?
Quality: What type of pain is it?
Radiation: Is the pain isolated or does it move around?
Severity: What is the intensity of the pain?
Time: Have you had the pain for a long period of time?
- What other history is important?
Other important factors from the patient’s medical history may include level of physical activity, weight, stress level, and any other recent conditions.
CASE STUDY PROGRESS
M.R. 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 his physician’s offi ce briefl y helped decrease symptoms.
- What tests could be done to determine the source of his problems?
Tests may include electrocardiogram, chest x-rays, and blood work to determine the potential cause of the chest pain (Mayo Clinic, 2013)
CASE STUDY PROGRESS
M.R. has smoked 1 pack of cigarettes a day 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.” M.R.
has dark circles under his eyes and complains of (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 (Motrin) 800 mg bid or tid for 4 weeks.
- Which factors in M.R.’s life are likely contributing to his chest pain and nausea? Explain how.
His weight gain has not helped his situation. In addition, his recent back injury and level of stress are likely to be contributing factors. However, his smoking and drinking are perhaps the most relevant causes of his current condition.
- What other potential problem could M.R. develop?
It is possible that he could develop COPD or emphysema in the future, or perhaps lung cancer. In addition, his alcohol intake is a problem and could lead to cirrhosis of the liver over time.
- What is a hiatal hernia, and what is its role in GERD?
A hiatal hernia is diagnosed when part of the stomach protrudes into the chest through the diaphragm, leading to acid reflux symptoms in many patients (Gillson, 2011).
PART ONE Medical-Surgical Cases
CASE STUDY PROGRESS
M.R. explains that 6 months ago his physician prescribed ranitidine (Zantac) 150 mg PO bid for heartburn, and that it worked great initially. Now he keeps a bottle of Tums or Rolaids in his truck and at
his bedside, in addition to the ranitidine, “because I always seem to need them.”
CASE STUDY PROGRESS
M.R.’s 12-lead ECG was normal, and the fi rst set of cardiac enzymes was normal. CBC showed WBC
6.0 thou/cmm, Hgb 15.0 g/dl, Hct 47%, platelets 220 thou/cmm. Complete metabolic panel (CMP)
revealed Na 140 mmol/L, K 3.7 mmol/L, BUN 20 mg/dl, creatinine 1.0 mg/dl, lipase 20 unit/L, amylase
18 units/L, PT 12.0 sec, INR 1.0. The chest x-ray (CXR) showed no abnormalities. Room air SaO2 is 94% and breathing is unlabored.
- What medication should be prescribed?
In light of his condition, a stronger medication should be prescribed, such as Prilosec or Prevacid to counteract the acid reflux.
- Why does the patient need to take the medication first thing in the morning?
This type of medication works best when it is taken prior to consuming any food or beverages throughout the day.
- What lifestyle modifications would you recommend for M.R. on discharge to prevent acid reflux?
It is recommended that the patient should consider an improved diet to remove foods which may cause acid reflux, such as acid-based products. In addition, he should lose weight and quit drinking and smoking.
- If M.R. was prescribed control substances, which agency monitors the prescription of controlled substances?
The Drug Enforcement Agency is the organization tasked with monitoring the prescription of controlled substances.
- Which schedule of controlled substances requires a written prescription that cannot be refilled?
Schedule II Controlled Substances cannot be refilled (Office of Diversion Control, 2013).
- Errors in prescription writing are possible. Which factors can contribute to errors in prescription writing?
Handwritten prescriptions, those written quickly, and those written without examining a patient’s full medical history can contribute to these errors.
- It has been suggested that specific things should be done to reduce the potential for problematic prescriptions. Select the factors that may alleviate the potential for problematic prescriptions.
||__x_ Write clearly or invest in an electronic prescription transmission system.
||___ When a patient has disclosed suicidal ideation; write for no more than a 7-day supply of any medication that could be lethal if taken all at once.
||_x__ Warn patients of side effects.
||_x__ Discontinue a medication when it causes a cautioned side effect.
||_x__ Get informed consent when a drug can cause permanent side effects and less risky alternatives are available.
||_x__ If prescribing differently from the directions on the drug manufacturer’s package insert, document the rationale for deviating from the package insert instructions and be prepared to prove that the standard of care supports the alternative prescribing regimen.
||_x__ Once a plan has been developed, try not to deviate from the established plan.
||__x_ When a medication is known to cause some adverse effects after long-term use, either avoid using the drug for long-term therapy or monitor carefully for the onset of potential problems.
Brouhard, Rod. (2013). Chest pain symptoms. Retrieved from
Mayo Clinic (2013). Tests and diagnosis. Retrieved from
MedlinePlus (2013). Chest pain. Retrieved from
Office of Diversion Control (2013). Controlled substance schedules. Retrieved from