Health Assessment Discussion 5
cindyrod14
SweetStudy.docx|
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Case 1 |
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Chief Complaint (CC) |
“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 |
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PMH |
No contributory |
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PSH |
Appendectomy at the age of 14 |
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Drug Hx |
No meds |
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Allergies |
Penicillin |
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Subjective |
Fever and chills, Lost appetite Flatulence No mucus or blood on stools |
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PE |
B/P 188/96; Pulse 89; RR 16; Temp 99.0; Ht 5,6; wt 110; BMI 17.8 |
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General |
well-developed female in no acute distress, appears slightly fatigued |
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HEENT |
Atraumatic, normocephalic, PERRLA, EOMI, arcus senilus bilaterally, conjunctiva and sclera clear, nares patent, nasopharynx clear, edentulous. |
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Neck |
Supple |
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Lungs |
CTA AP&L |
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Card |
S1S2 without rub or gallop |
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Abd |
positive bowel sounds (BS) in all four quadrants; no masses; no organomegaly noted; diffuse, mild, bilateral lower quadrant pain noted Mild diffuse tenderness. |
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GU |
Non contributory |
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Ext |
no cyanosis, clubbing or edema |
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Integument |
good skin turgor noted, moist mucous membranes |
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Neuro |
No obvious deformities, CN grossly intact II-XII |
Once you received your case number, 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.
