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)
5.What medication could have contributed to his symptoms?
6. What is the diagnosis?
7. What medication regimen would be ordered for treatment?