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.

QUESTION

1. What are signs and symptoms of anemia?
2. What is rebound tenderness? Guarding?
3. What do the vital signs reveal?
4. 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

Symptoms and Sign..of anaemia....

palpitation, easy fatigue, breathlessness ,dizziness, sometimes cramps in the legs . More importantly reducing capacity to resist infection, reduced concentrating capacity ,sometimes attention deficit disorder etc

....sometimes koilonychia or spoon shaped nail in iron deficiency anaemia,, glossy tongue,angular stomatitis or fissures at the corners of the mouth (angular stomatitis) frequently splenic enlargement is there in chronic cases.Pale skin,nails,tongue,conjunctiva.

Rebound tenderness,It is a clinical sign elicited by doctor.It means tenderness or feeling of pain during physical examination of a patient's abdomen (percussion) by a doctor If the patient is asked to cough gently or palpate the abdomen and see if there is any pain felt by the patient,then quickly removing the examiner's hand after giving pressure to the area will increase the pain. It is a sign of intra -abdominal disease.which may or may not affect parietal peritoneum

Guarding may be voluntary when voluntary contraction of intra abdominal muscle occur when pain is there after palpation of abdomen,

Involuntary guarding is the reflex contraction of abdominal muscle in a case of inflamed parietal peritoneum.

The vital signs blood pressure, pulse, temperature, respiration, height, and weight are reviewed and all are more or less normal e,g bradycardia =HR<60/min and tachycardia HR>100/min

Our motto to check vitals to see if the patient is in shock or blood loss..More than 100 beats per minute (bpm),HR systolic blood pressure of less than 90 mm Hg, cool extremities, syncope, and other obvious signs of shock will be revealed by vitals.

a.Inspection- Pallor of the face,tongue,nail bed though  Nutritional state is normal (height weight BMI)

b. Auscultation- Bowel sounds should be there with patient lying on his back and stethoscope on just the right side of the umbilicus ,in every 5-10 seconds . A gurgling noise of intestinal peristalsis.Wait for minimum 2 minutes to declare no bowel sounds as in case of peritonitis.

c. Percussion-not remarkable

d. Palpation- Rebound tenderness and guarding is present as discussed above

5.Patients have increased risk for Upper Gastrointestinal Tract Bleeding when taking steroids, aspirin, or NSAID therapy.Here use of painkillers may precipitate the condition of haemorrahage from gi tract.

6.What is the diagnosis? It is a case of Upper gastrointestinal bleeding due to peptic ulcer.

7.Treatment The therapy in upper gastrointestinal bleeding (UGIB) is to correct shock and coagulation abnormalities and to stabilize the patient. Then evaluation and treatment can proceed.

Intravenous (IV) fluids and  transfusion of packed red blood cells depending on haematocrit.. High doses of proton pump inhibitors (PPIs) may curtail the need for endoscopic therapy.