NUR 504 506

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 2


Case 1 Case 2 Case 3 Chief Compl aint (CC)

“I am here today due to frequent and watery bowel movements”

“I have pain in my belly” “neck swelling”

Histor y of Prese nt 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

A 25-year-old female presents to the emergency room (ER) with complaints of severe abdominal pain for 2 weeks . The pain is sharp and crampy It hurts if I run, sit down hard, or if I have sex

A 42-year-old African American female who refers that she has been noticing slow and progressive swelling on her neck for about a year. Also she stated she has lost weight without any food restriction

PMH No contributory Patient denies Patient denies

PSH Appendectomy at the age of 14

Surgical removal of benign left breast nodule 2 years ago

Drug Hx No meds Birth control No medication at the

time Allergi es Penicillin NKA NKA

Subje ctive

Fever and chills, Lost appetite Flatulence No mucus or blood on stools

Nausea and vomiting, Last menstrual period 5 days ago, New sexual partner about 2 months ago, No condoms, he hates them No pain, blood or difficulty with urination

Mild difficult to shallow, Neck feels tight, Pt states she feels Palpitations

Objective Data

PE B/P 188/96; Pulse 89; RR 16; Temp 99.0; Ht 5,6; wt 110; BMI 17.8

B/P 138/90; temperature 99°F;  (RR) 20; (HR) 110, regular; oxygen saturation (PO2) 96%; pain 5/10

B/P 158/90; Pulse 102; RR 20; Temp 99.2; Ht 5,4; wt 114; BMI 19.6

Gener al

well-developed female in no acute distress, appears slightly fatigued

acute distress and severe pain

42-year-old female appears thin. She is anxious – pacing in the room and fidgeting, but in no acute distress.

HEEN T

Atraumatic, normocephalic, PERRLA, EOMI, arcus senilus bilaterally, conjunctiva and sclera clear, nares patent, nasopharynx clear, edentulous.

Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition. Piercing in her right nostril and lower lip.

Bulging eyes

Neck Supple Diffuse enlargement of the thyroid gland

Lungs CTA AP&L CTA AP&L CTA AP&L

Card S1S2 without rub or gallop

S1S2 without rub or gallop

S1S2 without rub, Tachycardia

Abd

positive bowel sounds (BS) in all four quadrants; no masses; no organomegaly noted; diffuse, mild, bilateral lower quadrant pain noted Mild diffuse tenderness.

• INSPECTION: no masses or thrills noted; no discoloration and skin is warm to; no tattoos or piercings; abdomen is nondistended and round
 • AUSCULTATION: bowel sounds (BS) are normal in all four quadrants, no bruits noted
 • PALPATION: on palpation, abdomen is tender to touch in four quadrants; tenderness noted on light palpation, deep palpation reveals no masses, spleen and liver unremarkable
 • PERCUSSION: tympany heard in all quadrants, no dullness noted in abdominal area

benign, normoactive bowel sounds x 4

GU Non contributory

• EXTERNAL: mature hair distribution; no external lesions on labia • INTROITUS: slight green-gray discharge, no lesions • VAGINAL: normal rugae; moderate amount of green discharge on vaginal walls • CERVIX: nulliparous os with small amount of purulent discharge from os with positive cervical motion tenderness (CMT) • UTERUS: ante- flexed, normal size, shape, and position • ADNEXA: bilateral tenderness with fullness; both ovaries without masses • RECTAL: deferred • VAGINAL DISCHARGE: green in color

Non contributory

Ext no cyanosis, clubbing or edema

no cyanosis, clubbing or edema

no cyanosis, clubbing or edema

Integu ment

good skin turgor noted, moist mucous membranes

intact without lesions masses or rashes

Thin skin, Increase moisture

Neuro No obvious deformities, CN grossly intact II-XII

No obvious deficits and CN grossly intact II-XII

No obvious deficits and 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 instructor will assign you your case number and you will post on the case number you have been assigned.

• You will reply to the other two case studies (One of each). • 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.

• You should respond to at least two of your peers by extending, refuting/correcting, or adding additional nuance to their posts. Your reply posts are worth 2 points (1 point per response.) 

• All replies must be constructive and use literature where possibl

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 2


Case 1 Case 2 Case 3 Chief Compl aint (CC)

“I am here today due to frequent and watery bowel movements”

“I have pain in my belly” “neck swelling”

Histor y of Prese nt 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

A 25-year-old female presents to the emergency room (ER) with complaints of severe abdominal pain for 2 weeks . The pain is sharp and crampy It hurts if I run, sit down hard, or if I have sex

A 42-year-old African American female who refers that she has been noticing slow and progressive swelling on her neck for about a year. Also she stated she has lost weight without any food restriction

PMH No contributory Patient denies Patient denies

PSH Appendectomy at the age of 14

Surgical removal of benign left breast nodule 2 years ago

Drug Hx No meds Birth control No medication at the

time Allergi es Penicillin NKA NKA

Subje ctive

Fever and chills, Lost appetite Flatulence No mucus or blood on stools

Nausea and vomiting, Last menstrual period 5 days ago, New sexual partner about 2 months ago, No condoms, he hates them No pain, blood or difficulty with urination

Mild difficult to shallow, Neck feels tight, Pt states she feels Palpitations

Objective Data

PE B/P 188/96; Pulse 89; RR 16; Temp 99.0; Ht 5,6; wt 110; BMI 17.8

B/P 138/90; temperature 99°F;  (RR) 20; (HR) 110, regular; oxygen saturation (PO2) 96%; pain 5/10

B/P 158/90; Pulse 102; RR 20; Temp 99.2; Ht 5,4; wt 114; BMI 19.6

Gener al

well-developed female in no acute distress, appears slightly fatigued

acute distress and severe pain

42-year-old female appears thin. She is anxious – pacing in the room and fidgeting, but in no acute distress.

HEEN T

Atraumatic, normocephalic, PERRLA, EOMI, arcus senilus bilaterally, conjunctiva and sclera clear, nares patent, nasopharynx clear, edentulous.

Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition. Piercing in her right nostril and lower lip.

Bulging eyes

Neck Supple Diffuse enlargement of the thyroid gland

Lungs CTA AP&L CTA AP&L CTA AP&L

Card S1S2 without rub or gallop

S1S2 without rub or gallop

S1S2 without rub, Tachycardia

Abd

positive bowel sounds (BS) in all four quadrants; no masses; no organomegaly noted; diffuse, mild, bilateral lower quadrant pain noted Mild diffuse tenderness.

• INSPECTION: no masses or thrills noted; no discoloration and skin is warm to; no tattoos or piercings; abdomen is nondistended and round
 • AUSCULTATION: bowel sounds (BS) are normal in all four quadrants, no bruits noted
 • PALPATION: on palpation, abdomen is tender to touch in four quadrants; tenderness noted on light palpation, deep palpation reveals no masses, spleen and liver unremarkable
 • PERCUSSION: tympany heard in all quadrants, no dullness noted in abdominal area

benign, normoactive bowel sounds x 4

GU Non contributory

• EXTERNAL: mature hair distribution; no external lesions on labia • INTROITUS: slight green-gray discharge, no lesions • VAGINAL: normal rugae; moderate amount of green discharge on vaginal walls • CERVIX: nulliparous os with small amount of purulent discharge from os with positive cervical motion tenderness (CMT) • UTERUS: ante- flexed, normal size, shape, and position • ADNEXA: bilateral tenderness with fullness; both ovaries without masses • RECTAL: deferred • VAGINAL DISCHARGE: green in color

Non contributory

Ext no cyanosis, clubbing or edema

no cyanosis, clubbing or edema

no cyanosis, clubbing or edema

Integu ment

good skin turgor noted, moist mucous membranes

intact without lesions masses or rashes

Thin skin, Increase moisture

Neuro No obvious deformities, CN grossly intact II-XII

No obvious deficits and CN grossly intact II-XII

No obvious deficits and 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 instructor will assign you your case number and you will post on the case number you have been assigned.

• You will reply to the other two case studies (One of each). • 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.

• You should respond to at least two of your peers by extending, refuting/correcting, or adding additional nuance to their posts. Your reply posts are worth 2 points (1 point per response.) 

• All replies must be constructive and use literature where possibl