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. Your instructor will assign you your case number.
|
Case 1 |
|
|
Chief Complaint |
“I am here today due to frequent and watery bowel movements” |
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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 |
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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 |
Answer the following questions:
1.
What other subjective data would you obtain?
2.
What other objective findings would you look for?
3.
What diagnostic exams do you want to order?
4.
Name 3 differential diagnoses based on this patient presenting symptoms?
5.
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. Your initial post is worth 8 points.
· All replies must be constructive and use literature where possible.
