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For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases. You will work on case study # 1

Case 1Case 2Case 3Chief Complaint

(CC)

“I am here today due to frequent and watery bowel movements”“I have pain in my belly”“neck swelling”

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 hoursA 25-year-old female presents to the emergency room (ER) with complaints of severe abdominal pain for 2 weeks . The pain is sharp and crampy It hurts if I run, sit down hard, or if I have sexA 42-year-old African American female who refers that she has been noticing slow and progressive swelling on her neck for about a year. Also she stated she has lost weight without any food restriction

PMH

No contributory Patient deniesPatient denies

PSH

Appendectomy at the age of 14 Surgical removal of benign left breast nodule 2 years ago

Drug Hx

No medsBirth controlNo medication at the time

Allergies

PenicillinNKANKA

Subjective

Fever and chills, Lost appetite Flatulence No mucus or blood on stoolsNausea and vomiting, Last menstrual period 5 days ago, New sexual partner about 2 months ago, No condoms, he hates them No pain, blood or difficulty with urinationMild difficult to shallow, Neck feels tight, Pt states she feels PalpitationsObjective Data

PE

B/P 188/96; Pulse 89; RR 16; Temp 99.0; Ht 5,6; wt 110; BMI 17.8B/P 138/90; temperature 99°F;  (RR) 20; (HR) 110, regular; oxygen saturation (PO2) 96%; pain 5/10 B/P 158/90; Pulse 102; RR 20; Temp 99.2; Ht 5,4; wt 114; BMI 19.6

General

well-developed female in no acute distress, appears slightly fatiguedacute distress and severe pain42-year-old female appears thin. She is anxious – pacing in the room and fidgeting, but in no acute distress.

HEENT

Atraumatic, normocephalic, PERRLA, EOMI, arcus senilus bilaterally, conjunctiva and sclera clear, nares patent, nasopharynx clear, edentulous.

Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition. Piercing in her right nostril and lower lip.

Bulging eyes

Neck

SuppleDiffuse enlargement of the thyroid gland

Lungs

CTA AP&L

CTA AP&L

CTA AP&L

Card

S1S2 without rub or gallopS1S2 without rub or gallopS1S2 without rub, Tachycardia

Abd

positive bowel sounds (BS) in all four quadrants; no masses; no organomegaly noted; diffuse, mild, bilateral lower quadrant pain noted Mild diffuse tenderness.

INSPECTION: no masses or thrills noted; no discoloration and skin is warm to; no tattoos or piercings; abdomen is nondistended and round

• AUSCULTATION: bowel sounds (BS) are normal in all four quadrants, no bruits noted

• PALPATION: on palpation, abdomen is tender to touch in four quadrants; tenderness noted on light palpation, deep palpation reveals no masses, spleen and liver unremarkable

• PERCUSSION: tympany heard in all quadrants, no dullness noted in abdominal area

benign, normoactive bowel sounds x 4

GU

Non contributory• EXTERNAL: mature hair distribution; no external lesions on labia

• INTROITUS: slight green-gray discharge, no lesions

• VAGINAL: normal rugae; moderate amount of green discharge on vaginal walls

• CERVIX: nulliparous os with small amount of purulent discharge from os with positive cervical motion tenderness (CMT)

• UTERUS: ante-flexed, normal size, shape, and position

• ADNEXA: bilateral tenderness with fullness; both ovaries without masses

• RECTAL: deferred

• VAGINAL DISCHARGE: green in color Non contributory

Ext

no cyanosis, clubbing or edemano cyanosis, clubbing or edemano cyanosis, clubbing or edema

Integument

good skin turgor noted, moist mucous membranesintact without lesions masses or rashesThin skin, Increase moisture

Neuro

No obvious deformities, CN grossly intact II-XIINo obvious deficits and CN grossly intact II-XIINo obvious deficits and CN grossly intact II-XII

Once you received your case number, answer the following questions:

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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