Question

STORY 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.

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

1) Anemia is a condition in which there is less no of red blood cells which carry oxygen to the different parts of the body .anemia is manifested by various signs and symptoms like fatigue,weakness,pallor, tachycardia,leg cramps,dizziness,lack of interest or concentration towards work,shortness of breath,lack of sleep,pain in abdomen,back,legs.

2)Rebound tenderness is a clinical sign during physical examination of an abdomen .in this the patient feels the pain not when the abdomen is palpated but when it is released .it is also called as blumberg sign .The sign is considered positive when the patient feels the pain immediately after the released of the pressed abdomen it is an indicative of peritonitis.Abdominal guarding is a defence response of the abdomen wall to come together and go into spasm to prevent insult to an inflammed part of the peritoneum to guard it from further insults.Abdominal guarding is evidenced from a physical examination.on palpation he has

3) vital signs of Mr Marsh .shows that he has a normal temperature of 98.6.and normal respiratory rate of 18 breaths/min.Blood pressure systolic is on a lower side with 110/80mmhg and he has tachycardia with a hear rate of 100 beats/min. Tachycardia may be caused due to anemia as evidenced by his Hb if 9gm/dl.

4) IAPP is a pneumonic used to assess an abdomen the process starts with
inspection:The first step of abdominal assessment is to inspect the abdomen for shape ,contour of the abdomen Mr Marsh has a bloated abdomen with pulsation just above the umbilicus.no skin abnormality and herenia present on the abdomen .Auscultated for bowel sounds which is low less than 3 in two minutes ,aorta pulsation present .on palpation he has epigastric tenderness ,palpable mass and no ascities present .

The adomen examination along with the history is suggestive of peptic ulcers causing bleeding and black tarry stools and causing anemia .