DISCUSSION
| Chief Complaint (CC) |
|||
| 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.
