Gastrointestinal & Endocrine Nursing Presentation
|Case 1||Case 2||Case 3|
|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-oldEuropean American female presents to your practice with loose stoolsfor about three days. One event about every three hours||A 25-year-oldfemale presents to the emergency room (ER) with complaints of severeabdominal pain for 2 weeks . The pain is sharp and crampy It hurts if Irun, sit down hard, or if I have sex||A 42-year-oldAfrican American female who refers that she has been noticing slow andprogressive swelling on her neck for about a year. Also she stated shehas 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|
||No meds||Birth control||No medication at the time|
|Subjective||Fever and chills, Lost appetite Flatulence No mucus or blood on stools||Nausea andvomiting, Last menstrual period 5 days ago, New sexual partner about 2months ago, No condoms, he hates them No pain, blood or difficulty withurination||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 andsclera 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 andlower 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 bowelsounds (BS) in all four quadrants; no masses; no organomegaly noted;diffuse, mild, bilateral lower quadrant pain noted Mild diffusetenderness.|| INSPECTION: no masses or thrillsnoted; 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
VAGINAL DISCHARGE: green in color
|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|
- 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.