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