I am doing a case study for my skills lab on NG tubes. The case presented to me is below. The problem I'm having is that my textbooks don't have any...

I am doing a case study for my skills lab on NG tubes. The case presented to me is below. The problem I'm having is that my textbooks don't have any explanation on why ranitidine doesn't work. I do know that it is not a proton pump inhibitor but am not sure if I'm going in the right direction with this or if it is related to the fact that he had a moderately sized hiatal hernia.

The reason I am leaning towards it being medication related is because of the pantoprazole being mentioned several times throughout the scenario.

Finally, can you check my answer for number 5 and tell me if I am correct? I am not asking for the answer but need some guidance. The parts in book that cover esophagitis and hiatal hernia are not very detailed or big so I am struggling with this case study. We have 8 case studies and this is the only one I am truly struggling with.

Thank you.

You are assigned, M.R. is a 56 y/o general contractor who was admitted for dehydration and abdominal pain, related to nausea and vomiting. He reports having "heartburn" 3-4 times a day that is worse in the morning and when he skips meals. M.R. takes Rolaids or Tums to relieve the pain. He smokes one pack of cigarettes a day, consumes 3-4 beers on most nights and experienced a 20 lb weight gain over 10 years. M. R. stated that he feels "tired and old." He snores loudly and wakes up during the night with frequent nausea. You note dark circles under his eyes, pale skin and dry mucus membranes. He takes 800 mg of ibuprofen PO tid for a back injury and ranitidine 150 mg PO at bedtime for heartburn. M.R. states the ranitidine never really helped so he added the Rolaids and Tums.

V/S 130/80 lying, 115/70 standing, 110, 22, temp 98.6F, pulse ox 92% on room air.

Blood tests - Amylase 32 units, Lipase 20 units, Hgb 12.0 g/dl, and Hct 37%. An H. pylori breath test was negative.

1.    What factors in M.R.'s life could be contributing to his pain and nausea? Explain how.

Poor diet/skipping meals, excessive alcohol intake, too many antacids, taking too much ibuprofen, his job being physically demanding, lack of exercise

2.    Why did the ranitidine not help the heartburn?

3.    M.R. complains of nausea and vomits coffee-ground emesis with bright red blood. V/S remain the same. What concerns do you have about the emesis?

4.    If you did not see bright red blood how would you determine the emesis contained blood?

5.    The attending ordered a GI consult, the physician arrives and you report M.R.'s condition. You receive the following orders.

a.    NPO for emergent EGD

b.    Repeat CBC STAT

c.     02 by nasal cannula, titrate to maintain pulse ox >94%

d.    Type & crossmatch 2 units PRBCs and hold.

e.    Start a pantoprazole drip 8 mg/hr, preceded a 40 mg bolus IV

f.      Insert a Salem Sump tube and start a gastric lavage with NS

g.    Insert 2 large bore IVs and start NS at 100 mL/hr