STU Wk 5 Health Assessment Gastrointestinal & Endocrine Discussion

Question Description

icon Gastrointestinal & Endocrine

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.

Objective Data
	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
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:

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?
Give rationales for your each differential diagnosis.

Submission Instructions:

Your instructor will assign you your case number and you will post on the case number you have been assigned.
You will reply to the other two case studies (One of each).
Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources. Your initial post is worth 8 points.
You should respond to at least two of your peers by extending, refuting/correcting, or adding additional nuance to their posts. Your reply posts are worth 2 points (1 point per response.)
All replies must be constructive and use literature where possible.
Please post your initial response by 11:59 PM ET Thursday, and comment on the posts of two classmates by 11:59 PM ET Sunday.
You can expect feedback from the instructor within 48 to 72 hours from the Sunday due date.

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