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What other subjective data would you obtain?

January 28, 2023
Christopher R. Teeple

 For this, you will take on the role of a clinician who is building a health history for  the following case:

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

SubjectiveFever and chills, Lost appetite Flatulence No mucus or blood on stools

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

PSHAppendectomy at the age of 14

Drug Hx
No meds

AllergiesPenicillin

 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.

NeckSupple

Cardiology 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.

Integumentary good skin turgor noted, moist mucous membranes

 

 

Once you received your case number, answer the following:

  1. What other subjective data would you obtain?
  2. What other objective findings would you look for?
  3. What diagnostic examination do you want to order?
  4. Name 3 differential diagnoses based on this patient presenting symptoms?
  5. Give rationales for your each differential diagnosis.

 

Requirements:

at least 500 words ( 2 complete pages of content) formatted and cited in current APA style 7 ed  with support from at least 3 academic sources which need to be journal articles or books from 2019 up to now. NO WEBSITES allowed for reference entry. Include doi, page numbers, etc. Plagiarism must be less than 10%.

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