Running Head: CASE STUDY

Scholarly Assignment Case Study

Paige Lacy
Student No. N00835668
NURS 104
Prof. Karen Goodwin
October 28, 2014

Running Head: CASE STUDY

Scholarly Assignment Case Study

46-year-old male was brought to the urgent care clinic
complaining of chest pains. When the patient was brought in he stated
that he was working on his backyard building a patio, lifting heavy
patio stones. He suffers from asthma and Gastroesophageal Reflex
Disease (GERD). Patient is overweight and has a sedentary office job
and lifestyle. Respirations are wheezy sounding and patient
complained of shortness of breath, as well as indigestion due to not
eating much during the day.
Patients with GERD experience pain when stomach acid flows
back into an irritation similar to chest pain (Staff, 2014). This particular
disease can cause many symptoms such as shortness of breath, chest
pain, indigestion and obesity (Staff, 2014). GERD can be easily
controlled when an individual takes the time to make changes in their
daily lifestyle. In this case study I believe that the patients priority
problems are his shortness of breath and his sedentary lifestyle, which
is causing him to be overweight and experience GERD often.
Shortness of breath results when the patients acid reflux causes
the esophagus to narrow. When gastric acid reaches the vocal folds,
airways and lungs it can cause swelling, the result of this airway
damage can cause coughing or wheezy respiration sounds (Madell,
2012). I believe that the patients shortness of breath is caused by the
asthma and the fact that it was hot and humid out during the day while

Running Head: CASE STUDY

he was outside in the backyard building his new patio he became
dehydrated. The patient mentioned he did not eat much during the
day, assuming he was too bust to stop for food; this makes me believe
he also forgot to drink fluids throughout the day that make him
dehydrated, which can cause shortness of breath (Sircus, 2010). My
first priority problem with the patient is to keep him hydrated, make
sure he drinks lots of fluids to ensure he is restoring his body fluids. I
would use this time to explain to the patient how important staying
hydrated is, especially during hot humid days. You can lose water from
your body everyday when you do to the bathroom, sweat and exercise
(familydoctor.org editorial staff, 2011). I think explaining that a person
should drink at least 6 to 8, eight ounce glasses of water a day will
help the patient understand how much water a day is really needed
(familydoctor.org editorial staff, 2011). As well as how important it is
we continue to drink water throughout the everyday to ensure our fluid
balance in our bodies are stable to prevent dehydration
(familydoctor.org editorial staff, 2011).
In result of the patient having a sedentary office job and a
sedentary lifestyle that does not involve a proper diet or exercise to
keep his weight normal have caused him chest pain due to acid reflux.
While his GERD is causing all of these symptoms there are many ways
to controlling it. My second priority problem for this patient is to clarify
the importance of diet and exercise when dealing with GERD, and that

Running Head: CASE STUDY

changing his lifestyle according to his symptoms could help control his
GERD. For dietary purposes, the patient should avoid certain foods and
drinks, such as: Chocolate, peppermint, fried or fatty foods, coffee or
alcoholic beverages (Madell, 2012). Staying away from these particular
foods have been proven that it can help reduce the amount of stomach
acid travelling back up his esophagus causing chest pains. Acid reflux
can also be triggered by not eating, when an individual does not eat,
the stomach will start to initially eat itself or push the stomach acid
back up the esophagus as it has no where else to go. Another reason
for lifestyle to be a priority is because I believe the patient needs to
lose weight, avoid sitting down on the couch after being deskbound at
work all day; a couple examples would be to go for a walk, go to the
gym or invest in a hobby. Anything that requires physical activity will
help with his overweight problem, which eventually will help with his
GERD. To help reduce acid reflux the patient can also avoid wearing
tight clothing and belts, which will reduce the amount of acid reflux for
the patient (Smith, 2014). I chose sedentary lifestyle as a priority
because if the patient was educated on his disease he could lose
weight and eat better including avoiding the foods that trigger this
disease.
In conclusion, the 46-year-old male with complaints of chest
pains was caused by his asthma and GERD. If the patient took a break
during the day to have something to eat and drink lots of fluids during

Running Head: CASE STUDY

the day he probably wouldnt have suffered from dehydration and
chest pain caused by GERD. Now that the patient is educated on how
important it is to change his lifestyle to decrease the effects from
GERD and that during how humid days it is very essential to stay
hydrated by drinking plenty of water. With the symptoms that the
patient was presented with assured me that his priority problems were
to be treated for dehydration as well as being educated on how to stay
away from food that trigger acid reflux and to change his daily
activities from a sedentary lifestyle to an active lifestyle so that he can
lose weight and decrease his chances of having GERD symptoms.
Understanding gastroesophageal reflux disease is very important to
decrease an individuals restrictions on their daily lifestyle.

References

Familydoctor.org editorial staff. (2011,june1). Hydration: why its so

important. Retrieved October 23, 2014, from familydoctor.org:
www.familydoctor.org/familydoctor/en/prevention-wellness/foodnutrition/nutrients/dehydrations-why-its-so-important.html

Madell, R. (2012, June 30). Acid Reflux and Shortness of Breath.

Retrieved October 23,2014, from Healthline:
www.healthline.com/health/gerd/shortness-of-breath#1

Running Head: CASE STUDY

Sircus, D (2010, September 20). Dehydration. Retrieved October 23,

2014, from Dr.Sircus.com:
www.drsircus.com/medicine/water/dehydration-3

Smith, M. W. (2014, April 20). Heartburn/GERD Health Center. Retrieved

October 23,2014, from WebMD: www.webmd.com/heartburngerd/treating-acid-reflux-disease-with-diet-lifestyle-changes

Staff, M. C. (2014, July 31). Diseases and conditions GERD. Retrived

October 23,2014, from Mayo Clinic: www.mayoclinic.org/diseasesconditions/gerd/basics/definitions/con-2002501