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.

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 signs of anaemia are...........

• Easy fatigue and feeling of weakness
• Pale skin,pale tongue nail bed and conjunctiva
• shortness of breath sometimes associated with palpitation ,dizziness
• Inflammation or soreness of tongue
• Cold and clammy skin
• Brittle nails
• spoon shaped nail or koilonychia
• Poor appetite, especially in infants and children with iron deficiency anemia

What is rebound tenderness? Guarding?

Rebound tenderness is indicative of intra-abdominal disease but that does not mean that parietal peritoneum is inflammed..Rapidly taking away the examiner's hand from the patient's abdomen after deep palpation elicits pain.

Guarding is voluntary or involuntary. In voluntary guarding there is voluntary contraction of abdominal muscles during physical examination when patient feels pain during palpation

Involuntary guarding is present when there is inflammation of parietal peritoneum. which cause involuntary contraction of abodominal muscles.

What do the vital signs reveal?

Vitals are respiration rate, pulse,temperature, Blood pressure height and weight

if systolic BP falls below 60 mm of Hg it is alarming,

similarly respiration rate above 30 per minute is a warning sign and pulse >100/minute is tachycardia and <60/minute is bradycardia.

Here we have to assess if the patient has undergone shock or indicators of shock like  tachycardia, hypotension, and anuria is present.But our patient is not in shock in spite of bleeding peptic ulcer as evidenced by his vitals

a.Inspection- in well lit area if there is any visible veins in the wall of the abdomen suggestive of portal hypertension or distension..In present patient it should be unremarkable.

b. Auscultation- Stetho should be over the abdominal wall for the gurgling sound of the intestinal movements of peristalsis (every 5-10 seconds) will be heard. If no sound for 2 minutes peritonitis is suggestive or perforation . In present case no such thing should be there,

c. Percussion- for presence of Fluid or ascitis.

d. Palpation- Rebound tenderness or tenderness in the epigastrium is there.

What medication could have contributed to his symptom

Usually NSAIDs, Glucocorticoids, long use of smoking and irritant substances

The diagnosis here is bleeding peptic ulcer

Commonest symptom of both gastric and duodenal ulcers is epigastric pain characterized by a burning sensation which occurs after meals—classically, shortly after meals with gastric ulcers and 2-3 hours afterward with duodenal ulcers.

As diagnostic and therapeutic approach simultaneously in management of bleeding peptic ulcer is urgent esophago gastroduodenoscopy (EGD) .It is the treatment of choice along with medication

The ulcer can be visualized by endoscopy, assessment of degree of severity and arrest of active bleeding can be done by clipping.Also acid suppression by PPI.e.g Omeprazole pantoprazole etc rather than ranitidine etc