Nursing Question

Learning Goal: I’m working on a nursing discussion question and need an explanation and answer to help me learn.

  1. What other subjective data would you obtain?
  2. What other objective findings would you look for?
  3. What diagnostic exams do you want to order?
  4. Name 3 differential diagnoses based on this patient presenting symptoms?
  5. Give rationales for your each differential diagnosis.
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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