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

1. Anemia: it is the deficiency of hemoglobin in human body. Sign and symptoms are:

• weakness
• easy fatiguability
• shortness of breath
• dizziness
• sleepiness
• pale akin
• Fast heart rate
• brittle nails

2.rebound tenderness is presence of pain on releasing the pressure which was applied on abdomen. Guarding is tensing of abdominal muscles to avoid pain from internal inflammed organs.

3. Vital seems normal except tachycardia as heart rate is 100/ min

4. Inspection: nurse will observe for shape, size, contour, movement of abdomen. Skin colour to be noticed and observe belly button for hernia.

auscultation: listen for bowel sounds with stethoscope if they are present or not. Bowel sounds may be normal , hypoactive or hyperactive.

palpation: it is done to check for presence of rigidity, mass or pain in all nine quadrants of abdomen. Deep palpation is done to check organomegaly like liver or splenomegaly or intestinal masses.

percussion: it is listening sound produced by tapping finger on other finger placed on abdominal surface. That sound characterises the presence of hard or soft mass, air. It is helpful to estimate the size of organs like liver or spleen, to check for ovarian tumor.