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
What other subjective data would you obtain?
What other objective findings would you look for?
What diagnostic examination do you want to order?
Name 3 differential diagnoses based on this patient presenting symptoms?
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.