Case 1

 

Chief Complaint

(CC)

 

“I am here today due to frequent and watery bowel movements”

 

History of

Present Illness

(HPI)

 

A 37-year-old European American female presents to your practice with “loose stools” for about three days.

One event about every three hours

 

PMH

 

No contributory

 

PSH

 

Appendectomy at the age of 14

 

Drug Hx

 

No meds

 

Allergies

 

Penicillin

 

Subjective

 

Fever and chills, Lost appetite Flatulence No mucus or blood on stools

     

PE

 

B/P 188/96; Pulse 89; RR 16; Temp 99.0; Ht 5,6; wt

110; BMI 17.8

 

General

 

well-developed female in no acute distress, appears slightly fatigued

 

HEENT

 

Atraumatic, normocephalic, PERRLA, EOMI, arcus senilus bilaterally, conjunctiva and sclera clear, nares patent, nasopharynx clear, edentulous.

 

Neck

 

Supple

 

Lungs

 

CTA AP&L

 

Card

 

S152 without rub or gallop

 

Abd

 

positive bowel sounds (BS) in all four quadrants; no masses; no organomegaly noted; diffuse, mild, bilateral lower quadrant pain noted Mild diffuse tenderness

     

GU

 

Non contributory

 

 

Ext

 

no cyanosis, clubbing or edema

 

 

Integument

 

 

good skin turgor noted, moist mucous membranes

 

Neuro

 

No obvious deformities, CN grossly intact II-XII 

1. What other subjective data would you obtain?
2. What other objective findings would you look for?
3. What diagnostic examination do you want to order?
4. Name 3 differential diagnoses based on this patient presenting symptoms?
5. Give rationales for your each differential diagnosis.

Submission Instructions:

• Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.