Learning Goal: I’m working on a nursing discussion question and need an explanation and answer to help me learn.
| Chief Complaint
(CC) |
“I am here today due to frequent and watery bowel movement |
| 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 hour |
| Past medical history | No contributory |
| PAst surgical history | Appendectomy at the age of 1 |
| Drug Hx | No meds |
| Allergies | Penicillin |
| Subjective | Fever and chills, Lost appetite Flatulence No mucus or blood on stool |
| Objective Data | |
| Vital signs | 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&L |
| Card | S1 S2 without rub or gallop |
| Abd | positive bowel sounds (BS) in all four quadrants; no masses; no organomegaly noted; diffuse, mild, bilateral lower quadrant pain noted Mild diffuse tenderness. |
| GU | Non contributory |
| Ext | no cyanosis, clubbing or edema |
| Integument | good skin turgor noted, moist mucous membranes |
| Neuro | No obvious deformities, CN grossly intact II-XII |
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