PerfectCustomPapers | The role of a clinician who is building a health history

The role of a clinician who is building a health history

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:

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?

Sample Answer

Case Analysis: Frequent Watery Bowel Movements

Additional Subjective Data

To further understand the patient’s condition, I would inquire about the following:

Diet: Recent changes in diet, including increased intake of certain foods or beverages, or changes in dietary habits.
Travel: Recent travel history, especially to areas with known outbreaks of gastrointestinal illness.

Full Answer Section

Stress: Any recent significant stressors or emotional distress.
Medications: Any over-the-counter medications or supplements being used.
Family History: A family history of gastrointestinal disorders, such as irritable bowel syndrome (IBS) or inflammatory bowel disease (IBD).

Additional Objective Findings

I would also look for:

Dehydration: Signs of dehydration, such as dry mucous membranes, decreased skin turgor, and decreased urine output.
Abdominal tenderness or guarding: More localized abdominal pain or tenderness, especially in the right lower quadrant, which could suggest appendicitis.
Rectal examination: To assess for any abnormalities, such as hemorrhoids, fissures, or masses.
Stool examination: To test for blood, parasites, or other abnormalities.

Diagnostic Exams

Based on the patient’s symptoms, I would order the following diagnostic tests:

Complete blood count (CBC): To evaluate for anemia, infection, or other blood disorders.
Comprehensive metabolic panel (CMP): To assess electrolyte balance and kidney function.
Stool culture: To identify any bacterial or parasitic infections.
Stool test for occult blood: To check for bleeding in the gastrointestinal tract.
Thyroid function tests: To rule out thyroid disorders that can cause diarrhea.

Differential Diagnoses

Based on the patient’s presenting symptoms, three possible differential diagnoses include:

Acute gastroenteritis: A common cause of diarrhea, often caused by viral or bacterial infections.
Irritable bowel syndrome (IBS): A functional gastrointestinal disorder characterized by abdominal pain and altered bowel habits

This question has been answered.

Get Answer

No More Worries!

Paper Formatting

No Lateness!

Our Guarantees