N 510 Module 6: Discussion Question

Discussion Question:

Choose one of the following case studies from the Bruyere textbook and complete. Please post your answers, and then reply to two classmates.

• #17 – acute pancreatitis
• #18 – cirrhosis
• #19 – colorectal cancer
• #22 – diarrhea
• #23 – esophageal varices
• #24 – gastric cancer
• #25 – GERD
• #27 – peptic ulcer disease

Your initial posting should be 200 to 300 words in length and utilize at least one scholarly source other than the textbook. Please reply to at least two classmates. Replies to classmates should be between 100 and 200 words in length. To properly “thread” your discussion posting, please click on REPLY.

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Module #6 Discussion Question: Peptic Ulcer Disease

M.S. is a 56-year old Hispanic male who presents with complaints of four-week history of gradually increasing upper abdominal pain. He describes the pain as “burning” in nature, localized to the epigastrum, and that previously it had been relieved by drinking milk or Mylanta. The pain is much worse now and milk or antacids do not provide any relief. He scores the pain as a “7” on a scale of 1-10. The patient does not feel the pain radiating into his back and has not noticed any blood in his stools. He denies any nausea, vomiting, weight loss, shortness of breath, neurological symptoms, or chest pain with exercise. He maintains that his appetite is excellent.

He has been taking 400mg ibuprofen almost daily for knee pain for the last 18 months. He injured his right knee in a car accident 15 years ago. He also takes daily doses of 81 mg aspiring “for his heart”, although this has not been prescribed. He does not take any other prescriptions or OTC meds. The patient smokes 1 ½ packs of cigarettes every day and has done so for 5 years since his wife passed away.  He does not drink alcohol or use illegal drugs. The patient is allergic to meperidine and develops a skin rash when he is treated with it.

He admits to feeling “street out” as he recently lost his job of twenty years as an insurance salesman and has had difficulty finding another. M.S. has been feeling a bit tired lately. He was diagnosed with HTN (stage 1) three years ago and has been managing his elevated BP with diet and regular workouts at the gym. His younger brother also has HTN and both his parents suffered AMIs at a young age. M.S. has a history of gall stones and laparoscopic removal of his gallbladder six years ago. He also has a history of migraine headaches.

1. Identify three factors that may have contributed to a peptic ulcer in this patient.

The patient is suffering from peptic ulcer disease and contributing factors to this can be

daily intake of ibuprofen of 400mg for the past 18 months; self-medicating use of aspirin “for his heart”; Smoking cigarettes 1 ½ pack per day.

2. From the list of factors in question 1 that may have contributed to a peptic ulcer in this patient, which factor has likely played the most significant role?

The most likely factor that has contributed to a peptic ulcer in this patient would have to be the prolonged daily NSAID medication use of ibuprofen and aspirin. NSAIDs can cause damage to the gastro duodenal mucosa via several mechanisms, including the topical irritant effect of these drugs on the epithelium, impairment of the barrier properties of the mucosa, suppression of gastric prostaglandin synthesis, reduction of gastric mucosal blood flow and interference with the repair of superficial injury. (Wallace, 2000)

3. Why might the healthcare provider have inquired about possible shortness of breath or chest pain with exercise?

The health care provider would need to ask these questions as the patient as MI can present as gastric upset and the patient already has a past medical history with both parents suffering from AMI at a young age not disclosed.

Physical Exam and Lab Tests

The patient is a heavy Hispanic male in mild acute distress. He is rubbing his chest and upper abdomen.

Vital signs-T-98.8 F; BP-156/98 left arm sitting; P-90 and regular; RR-18 and unlabored; Height-5’10”; Weight-206 lbs.

4. Is this patient underweight, overweight, obese or is his weight healthy for his height?

According to the calculations, the patient has a BMI (body mass index) of 29.6 which puts him in the overweight category. (www.active.com, 2018)

5. Why might the PCP order an ECG for this patient?

An ECG should be ordered to rule out any cardiac changes due to the patients chief complaint as presentation for AMI can be similar to that of peptic ulcer disease. Specific cardiac lab tests should also be done to ensure that this is not a cardiac issue based on the patient’s presentation, past and family medical history.

HEENT, Neck, Skin

PERRLA, fundi w/o vascular changes; pharynx and nares clear; neck supple w/o bruits over carotid arteries; no thyromegaly or adenopathy; no JVD; skin warm with good turgor and slightly diaphoretic w/o cyanosis; yellowed teeth.

Lungs, Heart

Good lung expansion bilaterally; breath sounds clear; percussion w/o dullness throughout; RRR; no murmurs, gallops or rubs; S1 and S2 prominent.

Abdomen, Extremities

No abdominal bruits, masses or organomegaly; positive bowel sounds present throughout with no distention; epigastric tenderness with palpation but w/o rebound or guarding; no cyanosis, clubbing or edema; peripheral pulses +2 throughout.

Rectal Examination

No hemorrhoids present; prostate slightly enlarged but without nodules that suggest cancer; stool sample submitted for heme testing.

Neurological

AAO x 3, appropriately anxious; cranial nerves II-XII intact; strength 5/5 bilaterally; DTRs 2+ and symmetric; touch sensation intact; gait steady.

Laboratory Test Results

All blood chemistries including Na, K, Ca, BUN and Cr normal

WBC-7500/mm³ with NL WBC diff

Hct-37%

ALT, AST, total bilirubin- normal

Amylase-90 IU/L

ECG-normal sinus rhythm without evidence of ischemic changes

Stool heme-positive

6. What is the significance of the WBC count?

The WBC count of 7500/mm³  with NL WBC diff is within normal range for this patient as normal ranges for males is 5,000 to 10,000 per microliter of blood.  (www.lls.org, 2018)

7.  What is the significance of the Hct?

The hematocrit (Hct) is a percentage of  the ratio of the volume of red blood cells to the total volume of blood. Normal Hct levels for males are approximately from 45% to 52%. The patient’s Hct was low at 37% which could be indicative of anemia from too little iron, folic acid or vitamin B12; bleeding; inflammatory bowel disease; other diseases that might cause malnutrition and certain drugs. (www.lls.org, 2018)

8. What is the significance of the serum amylase concentration?

The blood amylase test is used to help diagnose and monitor acute pancreatitis.  When cells in the pancreas are injured, as happens with pancreatitis, or when the pancreatic duct is blocked by a gallstone or by a pancreatic tumor in rare cases, increased amounts of amylase are released into the blood. This increases concentrations of amylase in the blood and also in the urine as amylase is eliminated from the blood through the urine. Normal levels range within 26-102 IU/L.  The patient’s level is 90 IU/L which can rule out pancreatitis. (www.labtestsonline.org, 2018)

9. Why might tests for ALT and AST be appropriate for this patient?

The aspartate aminotransferase (ALT) and alanine aminotransferase (AST) are tests used to check for liver enzymes in the presence of liver damage.  The patient’s tests resulted in normal levels according to the lab. However, this patient needs education on the continued excessive use of NSAIDs and the risk for liver damage. (www.mayoclinic.org, 2018)

Endoscopy Results

Normal appearing esophagus; 1cm gastric ulcer with evidence of recent bleeding but no sighs of acute hemorrhage in the ulcer crater; rapid urease test negative.

10. What is the significance of the urease test result?

The rapid urease test is performed to diagnose H. pylori infection in gastric ulcer. Rapid urease test, also known as the CLO test (Campylobacter-like organism test), is a rapid diagnostic test for diagnosis of Helicobacter pylori. The basis of the test is the ability of H. pylori to secrete the urease enzyme, which catalyzes the conversion of urea to ammonia and carbon dioxide. (www.labtestsonline.org, 2018)

11. What type of management would be appropriate for this patient?

In patients with NSAID-induced ulcers, the offending agent should be discontinued. Medications that promote healing of PUD can be divided into three categories: 1. acid-anti-secretory agents (proton pump inhibitors and H2-receptor antagonists) 2. Agents that enhance GI defense mechanisms.  (Bruyere, 2009) Patients with PUD are encouraged to eat a balanced diet, and there is no justification for restrictive diets. Moderate alcohol intake is usually well tolerated. Smoking slows the rate of ulcer healing, increases the frequency of recurrences, and is discouraged.

References

BMI calculator (2018) Retrieved from https://www.active.com/fitness/calculators/bmi

Bruyere, H.   (2009) 100 Case Studies in Pathophysiology. Philadelphia, PA: Lippincott Williams & Wilkins.

Leukemia and Lymphoma Society. (2018) “Understanding Blood Counts.” Retrieved fromhttp://www.lls.org/managing-your-cancer/lab-and-imaging-tests/understanding-blood-counts

Lab Tests Online. (2018) “Amylase.” Retrieved from https://labtestsonline.org/tests/amylase

Mayo Clinic. (2018) “Toxic Hepatitis.” Retrieved from https://www.mayoclinic.org/diseases-conditions/toxic-hepatitis/symptoms-causes/syc-20352202

Wallace, J.L. (2000) “How do NSAIDs cause ulcer disease?” Baillieres Best Practice Clinical Gastroenterology. 2000 Feb 14 (1):147-59. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/10749095