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
Objective Data
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
rExt 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.
What other subjective data would you obtain?
What other objective findings would you look for?
What diagnostic exams do you want to order?
Name 3 differential diagnoses based on this patient presenting symptoms.
Give rationales for each differential diagnosis.
Submission Instructions:
least 500 words, formatted and cited in the current APA style with support from at least 2 academic sources other than your textbook. Y
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