Gastrointestinal & Endocrine For this Discussion, you will take on the role of a clinician

 

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.

Share This Post

Email
WhatsApp
Facebook
Twitter
LinkedIn
Pinterest
Reddit

Order a Similar Paper and get 15% Discount on your First Order

Related Questions

ase 3  Cases D.Z. is a holistic

ase 3  Cases D.Z. is a holistic nurse practitioner in a large multispecialty clinic. She works in the offices of surgeons, internists, and OBGYNs. Because the client population is so culturally diverse, D.Z. was hired to serve as a liaison between the providers of conventional healing and complementary and alternative

Case 1

Case 1 Chief Complaint (CC)  A 65-year-old male with chronic obstructive pulmonary disease (COPD) presents to the clinic with a cough he has had for the past 2 weeks. Subjective denies chest pain, denies night sweats, admits to having a fever but does not know the temp.  VS (BP) 115/75,

SOAP NOTE TEMPLATE Review the Rubric for more Guidance Demographics

SOAP NOTE TEMPLATE Review the Rubric for more Guidance Demographics Chief Complaint (Reason for seeking health care) History of Present Illness (HPI) Allergies Review of Systems (ROS) General: HEENT: Neck: Lungs: Cardio Breast: GI: M/F genital: GU: Neuro Musculo: Activity: Psychosocial: Derm: Nutrition: Sleep/Rest: LMP: STI Hx: Vital Signs Labs