| Chief Complaint
(CC) |
“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 below questions. Note that all your responses should apply to your specific patient from your assigned case study.
What other subjective data would you obtain?
What other objective findings would you look for?
What diagnostic exams do you want to order?
Name 3 differential diagnoses based on this patient presenting symptoms.
Give rationales for each differential diagnosis.