solved

Case 1 Case 2
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

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