For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases.
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
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