Assignment task: Gastrointestinal & Endocrine
For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases.
Case Scenario:
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: S1S2 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
Answer the below questions. Note that all your responses should apply to your specific patient from your assigned case study.
Question 1: What other subjective data would you obtain?
Question 2: What other objective findings would you look for?
Question 3: What diagnostic exams do you want to order?
Question 4: Name 3 differential diagnoses based on this patient presenting symptoms.
Question 5: Give rationales for each differential diagnosis.