Question

Case Study: Gastroesophageal Reflux Disease Patient Profile Mr. Liston is a 49-year-old male who goes to the health care provider because he is experiencing heartburn more frequently and it is keeping him awake at night. He had asthma as a child. He is currently taking Mylanta as needed for heartburn. Subjective Data 1. Has had occasional heartburn about once a week for a few years, but the last couple of months it has become more frequent and is now occurring almost 2. Describes the pain as a burning pain in his sternal area that is relieved by drinking milk or taking Mylanta 3. Pain worsens after he goes to bed and he has been having difficulty sleeping 4. Denies any nausea or vomiting Objective Data I. Temperature 98.4° F, pulse 78, respirations 16, blood pressure 124/70 2. Height 6'0",weight 270 lb 3. Physical exam normal, no abdominal pain or tenderness noted Question 1 As the admitting nurse, describe the additional history you would obtain from Mr. Liston

Answer 1

Many patients With myocardial infarction presents with complaint of heart burn and difficulty in sleeping at night. The admitting nurse should ask a few more questions to eliminate the risk of MI or heart failure.

1. Does the patient experiences shortness of breath during rest or physical activity

2. Does the pain in chest increases after physical exertion

3. Is the patient smoker, alcoholic

4. Patient leads a sedentary lifestyle or is physically active.

5. What medications he is currently taking

6. Family history of cardiovascular disease

7. Food habits