Showing Page:
1/7
CASE PRESENTATION
You are called in the early hours of the morning to a local residence in a lower income area
of town for a 47-year-old man who presents with severe abdominal pain that woke him
from his sleep. As you arrive on scene you notice the home is poorly maintained with a
moderate amount of “junk” around the property. You do not perceive any immediate
threats and you approach the front entrance where the door is open. You announce
yourself and your partner. The patient tells you to come in. As you enter you find the
patient, a thin, slightly emaciated man is sitting on the couch in obvious distress. He has
purposeful movements as you approach and ask his chief complaint. In a clear voice using
appropriate words he states he has intermittent abdominal pain for a week and was
awoken from his sleep about 15 minutes ago with intense abdominal pain. You note his
airway is clear, he is breathing rapidly and his pulse is fast and easily felt. Your partner
prepares the stretcher for transport while you continue to ask history questions and assess
vital signs. He describes the pain as an intermittent “gas-like” pain in the epigastric
region. He says he feels like he needs to “burp.” He continues to describe it as a band like
pattern around his upper abdomen and lower chest. It is most intense when he lies flat but
seems to have some relief when sitting upright smoking a cigarette. He took two tablets of
Naprosyn to reduce his typical aches and pains in his knees and ankles. He reports mild
nausea but has not vomited. His last bowel movement was yesterday and described as a
loose watery stool of normal color. He denies chest pain, palpitations nor shortness of
breath. He denies chronic medical conditions and does not take any medications, OTC,
prescription or herbal medications on a regular basis. He also denies recreational drug use
Showing Page:
2/7
but admits from 6-8 beers daily. He denies allergies.
On physical examination, his temperature is 35.4°C (95.7°F), blood pressure 111/62 mm
Hg, heart rate 97 beats per minute, and respiratory rate of 28 breaths per minute sating
98% on room air. He is diaphoretic, skin is normal in color and warm. He is unable to get
comfortable on the gurney and is writhing in pain. Mucus membranes are dry, eyes are
non-icteric with pupils that are round, equal and react to light. His lungs are equal, clear
to auscultation with good excursion bilaterally. No rales or rhonchi are found. The
abdomen is exquisitely tender on palpation to the epigastric region and both upper
quadrants with focal rebound tenderness and guarding. No tenderness or masses are felt
in the lower quadrants.
QUESTIONS
What other assessment or diagnostic information would you gather on this patient?
An assessment of this patient shall proceed with the following steps:
History of Present Illness (HOPI):
The history of present illness must bring out a correct narrative of the symptoms by the patient.
This includes:
Showing Page:
3/7
Are the symptom of an acute nature or is this a chronic and recurring issue
If recurrence is there, the timing as well as frequency of recurrence,
Any history of difficulty in swallowing (dysphagia)
Response of symptoms to eating or having medication.
History of aggravating factors like stress, exercise or exertion, particular foods, smoking
or alcohol consumption.
History of relieving factors like having certain foods, use of antacids preparations.
The goal of assessment is to seek concomitant Gastro Intestinal symptoms like being
anorexic, having nausea or vomiting, bloody vomiting, loss of weight, dark stools with occult
blood. Additional symptoms to assess comprise difficulty (dysponoic) breathing and
excessive sweating.
Past medical history
This pertinent past medical history which needs to be assessed consists of
Known Gastro Intestinal diseases
Any cardiac diseases or cardiac risk factor like hypertension and hyperlipidemias
Findings of past diagnostic assessments that have been done and
Any past treatments received.
Physical examination:
This shall include a review of vital signs like pulse, temperature and blood pressure.
Showing Page:
4/7
What pathological conditions would you suspect in this patient in other words, what are/is
your filed impression(s)?
The pathological conditions suspected in this patient based on the scenario are:
Dyspepsia
Gastric ulcer
Gastro Esophageal Reflux Disease (GERD)
Gastritis
Cholecystitis
Cholelithiasis
Pancreatitis
Ischemic Heart Disease
Anxiety disorders
Showing Page:
5/7
Compare and contrast the H
2
receptor Antagonists class of medications to the Proton
Pump Inhibitors class of medications. Would this patient benefit from either? Explain your
answer.
The H
2
receptor blockers are one class of medication used to treat dyspepsia, peptic ulcers,
gastro-esophageal reflux disease, gastritis and hyper-secretory states of the gut. The major
comparison and contrast points among the two are described as follows:
H
2
RECEPTOR
ANTAGONISTS
PROTON PUMP
INHIBITORS
Onset of Action
Within one hour
May take up to four days to start
working and providing relief
Duration of
action
They are effective for 9 to 12 hours
They are effective for as long as 24
hours to 3 days.
Drugs included
Cimetidine
Nizatidine
Famotidine
Ranitidine
Dexlansoprazole
Esomeprazole
Lansoprazole
Omeprazole
Showing Page:
6/7
Pantoprazole
Rabeprazole
Mechanism of
Action
They work by locking histamine,
which is a stimulus for the
production of acid by the stomach
cells.
As the name implies, by suppression of
proton pump, they block the secretion
of acid into the stomach.
Efficacy
They have lesser efficacy than PPIs
in suppressing acid secretion
They have higher efficacy in blocking
acid secretion than PPIS
Typical Dosing
Typical dosing is two times a day
(BD)
Typical dosing is one time a day (OD)
The patient will benefit from either of the two classes of medication compared and contrasted
above. The reason is that the primary culprit for patient’s symptoms and suspected pathology is
excess secretion of acid into the stomach which can be controlled by either of them. However, as
described above, PPIs have greater efficacy in controlling acid secretion into the stomach so the
patient will benefit more from them.
Showing Page:
7/7
If the patient were constipated, which gastrointestinal agent would you suggest to relieve
this problem? Explain your decision.
The treatment of constipation consists of:
Possibly discontinuation of culprit medication suspected to be causing constipation
Enhancement of dietary fiber in diet
A trial with a short course of osmotic laxatives
Osmotic laxatives like Lectulose syrup 15-30 ml once to four times a day are suggested for
use in this patient being the first line of treatment for those having constipation and is without
substantial gastrointestinal adverse effects.

Unformatted Attachment Preview

CASE PRESENTATION You are called in the early hours of the morning to a local residence in a lower income area of town for a 47-year-old man who presents with severe abdominal pain that woke him from his sleep. As you arrive on scene you notice the home is poorly maintained with a moderate amount of “junk” around the property. You do not perceive any immediate threats and you approach the front entrance where the door is open. You announce yourself and your partner. The patient tells you to come in. As you enter you find the patient, a thin, slightly emaciated man is sitting on the couch in obvious distress. He has purposeful movements as you approach and ask his chief complaint. In a clear voice using appropriate words he states he has intermittent abdominal pain for a week and was awoken from his sleep about 15 minutes ago with intense abdominal pain. You note his airway is clear, he is breathing rapidly and his pulse is fast and easily felt. Your partner prepares the stretcher for transport while you continue to ask history questions and assess vital signs. He describes the pain as an intermittent “gas-like” pain in the epigastric region. He says he feels like he needs to “burp.” He continues to describe it as a band like pattern around his upper abdomen and lower chest. It is most intense when he lies flat but seems to have some relief when sitting upright smoking a cigarette. He took two tablets of Naprosyn to reduce his typical aches and pains in his knees and ankles. He reports mild nausea but has not vomited. His last bowel movement was yesterday and described as a loose watery stool of normal color. He denies chest pain, palpitations nor shortness of breath. He denies chronic medical conditions and does not take any medications, OTC, prescription or herbal medications on a regular basis. He also denies recreational drug use but admits from 6-8 beers daily. He denies allergies. On physical examination, his temperature is 35.4°C (95.7°F), blood pressure 111/62 mm Hg, heart rate 97 beats per minute, and respiratory rate of 28 breaths per minute sating 98% on room air. He is diaphoretic, skin is normal in color and warm. He is unable to get comfortable on the gurney and is writhing in pain. Mucus membranes are dry, eyes are non-icteric with pupils that are round, equal and react to light. His lungs are equal, clear to auscultation with good excursion bilaterally. No rales or rhonchi are found. The abdomen is exquisitely tender on palpation to the epigastric region and both upper quadrants with focal rebound tenderness and guarding. No tenderness or masses are felt in the lower quadrants. QUESTIONS What other assessment or diagnostic information would you gather on this patient? An assessment of this patient shall proceed with the following steps: History of Present Illness (HOPI): The history of present illness must bring out a correct narrative of the symptoms by the patient. This includes: • Are the symptom of an acute nature or is this a chronic and recurring issue • If recurrence is there, the timing as well as frequency of recurrence, • Any history of difficulty in swallowing (dysphagia) • Response of symptoms to eating or having medication. • History of aggravating factors like stress, exercise or exertion, particular foods, smoking or alcohol consumption. • History of relieving factors like having certain foods, use of antacids preparations. The goal of assessment is to seek concomitant Gastro Intestinal symptoms like being anorexic, having nausea or vomiting, bloody vomiting, loss of weight, dark stools with occult blood. Additional symptoms to assess comprise difficulty (dysponoic) breathing and excessive sweating. Past medical history This pertinent past medical history which needs to be assessed consists of • Known Gastro Intestinal diseases • Any cardiac diseases or cardiac risk factor like hypertension and hyperlipidemias • Findings of past diagnostic assessments that have been done and • Any past treatments received. Physical examination: This shall include a review of vital signs like pulse, temperature and blood pressure. What pathological conditions would you suspect in this patient in other words, what are/is your filed impression(s)? The pathological conditions suspected in this patient based on the scenario are: • Dyspepsia • Gastric ulcer • Gastro Esophageal Reflux Disease (GERD) • Gastritis • Cholecystitis • Cholelithiasis • Pancreatitis • Ischemic Heart Disease • Anxiety disorders Compare and contrast the H2 receptor Antagonists class of medications to the Proton Pump Inhibitors class of medications. Would this patient benefit from either? Explain your answer. The H2 receptor blockers are one class of medication used to treat dyspepsia, peptic ulcers, gastro-esophageal reflux disease, gastritis and hyper-secretory states of the gut. The major comparison and contrast points among the two are described as follows: H2 RECEPTOR PROTON PUMP ANTAGONISTS INHIBITORS Within one hour Onset of Action May take up to four days to start working and providing relief They are effective for 9 to 12 hours Duration of They are effective for as long as 24 hours to 3 days. action Drugs included Cimetidine Dexlansoprazole Nizatidine Esomeprazole Famotidine Lansoprazole Ranitidine Omeprazole Pantoprazole Rabeprazole They work by locking histamine, As the name implies, by suppression of Mechanism of which Action is a stimulus for the proton pump, they block the secretion production of acid by the stomach of acid into the stomach. cells. Efficacy They have lesser efficacy than PPIs They have higher efficacy in blocking in suppressing acid secretion Typical Dosing acid secretion than PPIS Typical dosing is two times a day Typical dosing is one time a day (OD) (BD) The patient will benefit from either of the two classes of medication compared and contrasted above. The reason is that the primary culprit for patient’s symptoms and suspected pathology is excess secretion of acid into the stomach which can be controlled by either of them. However, as described above, PPIs have greater efficacy in controlling acid secretion into the stomach so the patient will benefit more from them. If the patient were constipated, which gastrointestinal agent would you suggest to relieve this problem? Explain your decision. The treatment of constipation consists of: • Possibly discontinuation of culprit medication suspected to be causing constipation • Enhancement of dietary fiber in diet • A trial with a short course of osmotic laxatives Osmotic laxatives like Lectulose syrup 15-30 ml once to four times a day are suggested for use in this patient being the first line of treatment for those having constipation and is without substantial gastrointestinal adverse effects. Name: Description: ...
User generated content is uploaded by users for the purposes of learning and should be used following Studypool's honor code & terms of service.
Studypool
4.7
Trustpilot
4.5
Sitejabber
4.4