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-...
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 off and on, 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, and a foul, bitter taste in his mouth. Recently, he has developed nausea, without emesis,
that is worse in the morning or after skipping meals. He reports having "heartburn" three or four times a day. When this
happens, he takes a couple of 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 BP - 130/80 lying and 120/72 standing, HR- 100, RR - 20, T - 98.6°F (37° C), and SpO 2 - 92%
on room air. A 12-lead electrocardiogram (ECG) showed normal sinus rhythm with a rare premature ventricular
contraction (PVC).
Family history, nutrition, smoking, and drinking habits, pain relief, surgical history, foods or behaviors precipitate or
worsen symptoms, OTC drugs (NSAIDS), PMH, eating disorder history, previous evaluation of chest pain, sleep patterns-
apnea, choking, dysphagia, weight gain or loss, tooth enamel erosion
M.R. indicates that usually, the chest pain is relieved by his antacids but this time, they had no effect. A "GI cocktail"
consisting of Mylanta and viscous lidocaine given at his physician's office briefly helped decrease symptoms.
4. What tests can be done to determine the source of his problems?
M.R. has smoked one pack of cigarettes a day for the past 35 years, drinks two or three 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 constant 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.
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