Chief Complaint (CC) “I am here today due to frequent and watery bowel movement


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
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
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 your each differential diagnosis.


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