Description
**********************************************************************CASE #2************************************************************
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:
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.
Grading Rubric
Your assignment will be graded according to the grading rubric.
Discussion Rubric
Criteria Ratings Points
Identification of Main Issues, Problems, and Concepts
Distinguished – 5 points
Identify and demonstrate a sophisticated understanding of the issues, problems, and concepts.
Excellent – 4 points
Identifies and demonstrate an accomplished understanding of most of issues, problems, and concepts.
Fair – 2 points
Identifies and demonstrate an acceptable understanding of most of issues, problems, and concepts.
Poor – 1 point
Identifies and demonstrate an unacceptable understanding of most of issues, problems, and concepts.
5 points
Use of Citations, Writing Mechanics and APA Formatting Guidelines
Distinguished – 3 points
Effectively uses the literature and other resources to inform their work. Exceptional use of citations and extended referencing. High level of APA precision and free of grammar and spelling errors.
Excellent – 2 points
Effectively uses the literature and other resources to inform their work. Moderate use of citations and extended referencing. Moderate level of APA precision and free of grammar and spelling errors.
Fair – 1 point
Ineffectively uses the literature and other resources to inform their work. Moderate use of citations and extended referencing. APA style and writing mechanics need more precision and attention to detail.
Poor – 0 points
Ineffectively uses the literature and other resources to inform their work. An unacceptable use of citations and extended referencing. APA style and writing mechanics need serious attention.
3 points
Response to Posts of Peers
Distinguished – 2 points
Student constructively responded to two other posts and either extended, expanded or provided a rebuttal to each.
Fair – 1 point
Student constructively responded to one other post and either extended, expanded or provided a rebuttal.
Poor – 0 points
Student provided no response to a peer’s post.
2 points
Total Points 10
