Question

CHIEF COMPLAINT: "I have been having dark stool and stomach pain for 3 days.”

HISTORY OF PRESENT ILLNESS: Mr. Marsh is a 32 year old who has been recently promoted to junior partner at a prestigious law firm. He is proud of his accomplishments at such a young age, and after being with the firm for a short time. He admits to feeling pressure and stress due to this new stage. He’s been having stomach pain for about a month, but it has worsened over the past few days. He reports that his stool has a dark, black appearance as well. Because of his hectic schedule, he does not really eat much, but when he does eat, he has a burning pain after meals. He takes medications for pain relief.

Prior to this visit, Mr. Marsh is healthy. His past medical history was for a tonsillectomy & adenoidectomy at age 10. Denies smoking, drinking or recreational drug use. He has annual check-ups as scheduled.

PHYSICAL EXAMINATION: AAOx 3. Well groomed, well nourished white male. Vital signs: BP 110/80 mmHg, HR 100/bpm right arm sitting, RR-18/bpm, T 98.6

HEENT/SKIN: Head is normocephalic. PERRLA. Tympanic membrane pearly gray. Patent nares. No bulging turbinates. Neck supple, trachea midline. Pallor of face. Mucous membranes moist, intact.

CARDIOVASCULAR: Lungs are clear to auscultation and percussion. S1, S2. No murmurs, bruit or thrills. Peripheral pulses are present but are rapid and weak.

ABDOMEN/RECTUM: To be completed by the nurse.

Rectal examination revealed black, tarry stool.

LABORATORY TESTS: Hemoglobin 9gm/dL, Hematocrit 27%, MCV 90. WBC 13,000/mm. PT/PTT - normal. BUN 12 mg/dL, Creatinine 0. 8 mg/dL. EKG-normal sinus rhythm, Chest x-ray -normal. X-ray of abdomen (kidney, ureter, bladder-KUB) is unremarkable.

What are signs and symptoms of anemia?

What is rebound tenderness? Guarding?

What do the vital signs reveal?

What would your abdominal assessment reveal? (Think IAPP)

a.Inspection-

b. Auscultation-

c. Percussion-

d. Palpation-

5.What medication could have contributed to his symptoms?

6. What is the diagnosis?

7. What medication regimen would be ordered for treatment?

Answer 1

Anemia is a common hematological disorder resulting from lack of red blood cells that is responsible to carry oxygen to the vital organs. The types of anemia are iron deficiency a common type resulting from lack of iron in the body,Hemolytic anemia as a result of excess break done of red blood cells as a result of infection,autoimmune or congenital diseases. The symptoms of anemia includes: fast irregular heart beat,fatigue,weakness,breathing difficulty,cold clammy skin.paleness and chest pain. The signs includes koilonychia,angular cheilitis,splenomegaly,pallor.

Rebound tenderness is the experience of pain on touch. It is also termed as Blumbergs sign. On physical examination the provider apples pressure over the abdomen using his hands if patient feels pain on touch this is explained as rebound tenderness. It is more common in peritonitis, perforation of bowel.cirrhosis,rupture of appendix,ulcer disease,inflammation of diverticulum,infections.

Guarding is defined as the voluntary contraction of the abdominal wall by the patient in order to reduce the pain. It is often noticed in patient experience pain secondary to peritonitis, perforation of bowel.cirrhosis,rupture of appendix,ulcer disease,inflammation of diverticulum,infections.

Vital signs: BP 110/80 mmHg, HR 100/bpm right arm sitting, RR-18/bpm, T 98.6 it reveals stable vitals.

Abdominal examination:

Inspection: No skin abnormalities,presence of guarding,no dilated vessels,no bluish discoloration on umbilicus,no lesions or masses.

Auscultation:bowel sounds heard,no bruits

Percussion : No ascites

Palpation: Rebound tenderness present.

Pain after meals suggestive of peptic ulcer disease. Black tarry stools shows iron deficiency anemia.