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
Case
2
Case
3
Chief 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 hours
A 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 sex
A 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 denies
Patient denies
PSH
Appendectomy at the age
of 14
Surgical removal of
benign left breast nodule 2 years ago
Drug Hx
No meds
Birth control
No medication at the
time
Allergies
Penicillin
NKA
NKA
Subjective
Fever and chills, Lost
appetite Flatulence No mucus or blood on stools
Nausea 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 urination
Mild difficult to shallow,
Neck feels tight, Pt states she feels Palpitations
Objective
Data
PE
B/P 188/96; Pulse
89; RR 16; Temp 99.0; Ht 5,6; wt 110; BMI 17.8
B/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 fatigued
acute distress and
severe pain
42-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
Supple
Diffuse enlargement of
the thyroid gland
Lungs
CTA AP&L
CTA AP&L
CTA AP&L
Card
S1S2 without rub or
gallop
S1S2 without rub or
gallop
S1S2 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 edema
no cyanosis, clubbing
or edema
no cyanosis, clubbing
or edema
Integument
good skin turgor noted,
moist mucous membranes
intact without lesions
masses or rashes
Thin skin, Increase
moisture
Neuro
No obvious deformities,
CN grossly intact II-XII
No obvious deficits and
CN grossly intact II-XII
No obvious deficits and
CN grossly intact II-XII
Once you received your case number, 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 500 words, formatted and cited
in current APA 7th style with support from at least 3 academic sources.
·
Turnitin similarity should be less than 14%
·
Quotes “…” cannot be used at a higher learning level for your
assignments, so sentences need to be paraphrased and referenced.
·
Acceptable references include scholarly journal articles or
primary legal sources (statutes, court opinions), journal articles, and books
published in the last five years. No websites to be referenced without
prior approval.
Textbook(s)
1. Rhoads, J., Demler, T. L., & Dlugasch, L. (2021). Advanced health
assessment and
diagnostic reasoning (4th ed.). Jones & Bartlett Learning.
ISBN: 9781284170313
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will take on the role of a clinician who is building a first appeared on Elite Writers.
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will take on the role of a clinician who is building a appeared first on Elite Writers.
