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  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 (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

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.