Care Plan

Nursing Care Plan Case StuCHIEF COMPLAINT: "I'm passing black stool" and lightheadedness - 3 days.

HISTORY OF PRESENT ILLNESS: Mr. Murphy is a 45-year-old advertising executive who presents to the

emergency room complaining of the passage of black stools x 3 days and an associated lightheadedness. He also

relates that he cannot keep up with his usual schedule because of fatigability. Upon further questioning he states that

his stools are not only black, but are sticky and malodorous. He further complains of recent worsening of a chronic

epigastric burning which had been a problem off/on for years. He had doubled his usual dose of tums without

significant relief of the burning. He has 2-3 martinis at lunch and another cocktail before dinner. He takes NSAIDS

as needed for back pain and recently started on one aspirin per day for cardiac prophylaxis. He smokes two packs of

cigarettes per day and an occasional cigar. He was told of an ulcer in the distant past but had no specific evaluation

or treatment for same.

Mr. Murphy has been treated for hypertension for eight years but denies any known cardiac history. His weight is

stable to increased and he claims to have an excellent appetite. He has a normal bowel habit and has not had prior

black stools. He has had no abdominal surgery and denies bleeding tendencies or prior transfusion.

PHYSICAL EXAMINATION: Examination reveals an alert, oriented, overweight male. He appears anxious and

somewhat restless. Vital signs are as follows. Blood Pressure 120/80 mmHg, Heart Rate 110/min - Supine; BP 90/60

mmHg; HR Thready - Standing (Patient complains of dizziness upon standing). Respiratory Rate - 20 /minute;

Temperature 98 F.

HE-ENT/SKIN: Facial pallor and cool, moist skin are noted. No telangiectasia of the lips or oral cavity are noted.

No spider nevi are seen. The parotid glands appear full.

CHEST: Lungs are clear to auscultation and percussion. The cardiac exam reveals regular rhythm with an S4. No

murmur is appreciated. Peripheral pulses are present but are rapid and weak.

ABDOMEN/RECTUM: The abdomen reveals a rounded abdomen. Bowel sounds are hyperactive. There is

moderate tenderness in the epigastrium. The liver is percussed to 13 cm ; the edge feels firm. The spleen was not felt

and no masses were appreciated; the exam was felt to be suboptimal secondary to the patient's obesity. Rectal

examination revealed black, tarry stool.

There are no dupuytren's contractions.

LABORATORY TESTS: Hemoglobin 9gm/dL, Hematocrit 27%, MCV 90. WBC 13,000/mm. PT/PTT - normal.

BUN 45mg/dL, Creatinine 1.0 mg/dL. Chest x-ray - normal. X-ray of abdomen (kidney, ureter, bladder - KUB) is


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