Gastrointestinal & Endocrine Nursing Presentation
| 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-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 | |
| 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 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 |
| 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 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 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 |
- 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.
