CASE STUDY
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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. Hes 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?
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DISCUSSION
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Please write 1 paragraph for each of the following (total 3 paragraphs) and each paragraph shall be no more than 6 sentences.
*** Minus 1 point for extra long paragraphs or over 9 sentences.
(Make sure to post in the assignment & discussion tabs)
1. What is the difference between osteoporosis, osteopenia & osteomalacia?
2. Name 3 treatments for osteoporosis.
3. For what reason would a wrench need to be readily accesible for a patient on an orthopedic unit?
4. What is the proper order/sequence to assess the GI system?
5. Name one medication that affects the oral cavity (i.e. gums).
