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Get it written →Chief Complaint- “I am here today due to frequent and watery bowel movements” History of Present Illness- A 37-year-old European American female presents to your practice with “loose stools” for about three days. One event about every three hours Patient Medical History- No contributory Patient Surgical History- Appendectomy at the age of 14 Drug History- No meds Allergies-Penicillin Drug History-No meds Subjective- Fever and chills, Lost appetite Flatulence No mucus or blood on stools Objective Vital Signs- 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 Head, Ears, Eyes, Nose, Throat- Atraumatic, normocephalic, PERRLA, EOMI, arcus senilus bilaterally, conjunctiva and sclera clear, nares patent, nasopharynx clear, edentulous. Neck-Supple Lungs- CTA AP&L Cardiovascular- S1S2 without rub or gallop Abdomen- positive bowel sounds (BS) in all four quadrants; no masses; no organomegaly noted; diffuse, mild, bilateral lower quadrant pain noted Mild diffuse tenderness. Genitourinary- noncontributory External-no cyanosis, clubbing or edema Neuro-No obvious deformities, CN grossly intact II-XII 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 each differential diagnosis
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