Description
The client, PJ, is a 60-year-old factory worker. PJ is admitted to the Emergency Department (ED) with a hemoptysis and severe acid reflux. Upon initial assessment, PJ is sitting in an upright position, guarding the abdomen and appears pale and diaphoretic. Vital signs are as follows: T 36.6ºC, HR 66 bpm and regular, BP 150/70 mmHg, RR 16 breaths/min, O2 saturation 98% on RA. PJ’s abdomen appears to be slightly distended with present bowel sounds upon auscultation. PJ reports a sharp, burning type of pain and rates it at 8/10 on a scale of 0-10 in the epigastric region.
The client reports a long history of osteoarthritis. PJ states they have been taking OTC Aspirin® 325mg PO QID for the past 6 months for osteoarthritic pain. PJ tells the nurse that they have never felt epigastric and abdominal pain in such severity and became extremely concerned when they saw blood in their vomit and began feeling extremely weak, which is why they came to the ED.
PJ is treated in the ED for mild dehydration and acid reflux and is sent discharged home once stabilized with a prescription of Zantac® 150mg PO BID.
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