Chief Criticism (CC) “I’m here this day attributable to frequent and watery bowel movements” History of Most up-to-date Illness (HPI)A 37-365 days-primitive European American feminine gifts to your apply with “free stools” for about three days. One event about every three hours PMHNo contributory PSHAppendectomy on the age of 14 Drug Hx No meds AllergiesPenicillin SubjectiveFever and chills, Misplaced appetite Flatulence No mucus or blood on stools PEB/P 188/96; Pulse 89; RR 16; Temp 99.0; Ht 5,6; wt 110; BMI 17.8 Generalwell-developed feminine in no acute ruin, looks somewhat fatigued HEENTAtraumatic, normocephalic, PERRLA, EOMI, arcus senilus bilaterally, conjunctiva and sclera sure, nares patent, nasopharynx sure, edentulous. NeckSupple LungsCTA AP&L CardS1S2 without rub or trip Abdpositive bowel sounds (BS) in all four quadrants; no loads; no organomegaly infamous; diffuse, gentle, bilateral lower quadrant effort infamous Silent diffuse tenderness. GU Non contributory Extno cyanosis, clubbing or edema Integumentgood skin turgor infamous, moist mucous membranes NeuroNo evident deformities, CN grossly intact II-XII Part on Facebook Tweet Note us Sample Respond Abstract of the Affected person’s Case A 37-365 days-primitive feminine gifts with a 3-day history of frequent, watery bowel movements (one every 3 hours), low-grade fever (99.0°F), chills, lack of appetite, flatulence, and gentle, diffuse lower quadrant abdominal effort with gentle diffuse tenderness. Her BMI is low (17.8). Physical exam finds she is somewhat fatigued, and her preliminary BP is elevated (188/96), though this might occasionally well also very well be stress-linked. She has sure bowel sounds in all four quadrants. Key Questions to Query Stool Traits: Detailed description of stool (coloration, consistency, smell, presence of blood/mucus). Ache: Portray the abdominal effort (involving, dreary, constant, intermittent, region). Associated Symptoms: Nausea, vomiting, urgency, tenesmus, weight loss, dizziness, switch in urination. Exposures: Crawl, food/water so Corpulent Respond Share Menstrual History: Rule out pregnancy. Key Physical Examination Findings Vitals: Orthostatic blood stress and pulse are notable to assess for dehydration. Abdominal: Detailed palpation for tenderness, guarding, rebound. Auscultate bowel sounds. Rectal exam with Hemoccult/FIT. Traditional: Assess hydration position (mucous membranes, skin turgor). Differential Diagnoses Acute Viral Gastroenteritis Acute Bacterial Gastroenteritis / Food Poisoning Clostridioides difficile (C. diff) Infection Parasitic Infection Temperamental Bowel Syndrome (IBS) with Diarrhea (IBS-D) Exacerbation Inflammatory Bowel Disease (IBD) Lactose Intolerance / Varied Food Intolerance Hyperthyroidism Urged Tests Stool Reviews: Custom, C. diff toxin, Ova and Parasites (O&P) x 3, Fecal Calprotectin/Lactoferrin, Fecal Occult Blood Test (FOBT) or Fecal Immunochemical Test (FIT). Blood Tests: CBC with differential, BMP, CRP/ESR, TSH with reflex T4, Serum Being pregnant Test (Quantitative hCG). Imaging: Abdominal X-ray (KUB). Administration Immediate: Rehydration (oral or IV), antiemetics, bland food map, effort management. Based totally on Outcomes: Antibiotics for bacterial infection, impart medications for C. diff or parasitic infection, referral for IBD if indicated. Affected person Training: Hygiene, “pink flag” symptoms, dietary progression, apply-up. This quiz has been answered. Uncover Respond
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