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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. Your instructor will assign you your case number. Mine is case #3
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 37yearold European American female presents to your practice with “loose stools” for about three days. One event about every three hoursA 25yearold 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 42yearold 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 PMHNo contributory Patient deniesPatient denies PSHAppendectomy at the age of 14 Surgical removal of benign left breast nodule 2 years agoDrug Hx
No medsBirth controlNo medication at the timeAllergiesPenicillinNKANKASubjectiveFever 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 PEB/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 Generalwelldeveloped female in no acute distress, appears slightly fatiguedacute distress and severe pain42yearold female appears thin. She is anxious – pacing in the room and fidgeting, but in no acute distress. HEENTAtraumatic, 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 NeckSuppleDiffuse enlargement of the thyroid glandLungsCTA AP&L
CTA AP&LCardS1S2 without rub or gallopS1S2 without rub or gallopS1S2 without rub, TachycardiaAbdpositive bowel sounds (BS) in all four quadrants; no masses; no organomegaly noted; diffuse, mild, bilateral lower quadrant pain noted Mild diffuse tenderness.
benign, normoactive bowel sounds x 4GU Non contributory• EXTERNAL: mature hair distribution; no external lesions on labia
• INTROITUS: slight greengray 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: anteflexed, normal size, shape, and position
• ADNEXA: bilateral tenderness with fullness; both ovaries without masses
• RECTAL: deferred
• VAGINAL DISCHARGE: green in color Non contributoryExtno cyanosis, clubbing or edemano cyanosis, clubbing or edemano cyanosis, clubbing or edemaIntegumentgood skin turgor noted, moist mucous membranesintact without lesions masses or rashesThin skin, Increase moistureNeuroNo obvious deformities, CN grossly intact IIXIINo obvious deficits and CN grossly intact IIXIINo obvious deficits and CN grossly intact IIXII
Once you received your case number, answer the following questions:
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