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Asked by nandy_ressus_cup
  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    
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 exams do you want to order?
Name 3 differential diagnoses based on this patient presenting symptoms?
Give rationales for your each differential diagnosis.

 

 

 

SCIENCE
HEALTH SCIENCE
NURSING
NUR 504

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