Assignment Task:
Case:
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: A traumatic, normocephalic. PERRLA, EOMI, arcus, senilus bilaterally, conjunctiva and sclera clear, cores patent, nasopharynx clear, Edentulous.
Neck: Supple
Lungs: CTA AP&L
Card: S 152 without rub or gallop
Abd: positive bowel sounds (BS) in all four quadrants: no masses: no organomegaly noted: din use, mild, bilateral low 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
Q1. What other subjective data would you obtain?
Q2. What other objective findings would you look for?
Q3. What diagnostic exams do you want to order?
Q4. Name 3 differential diagnoses based on this patient presenting symptoms?
Q5. 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