Learning Goal: I’m working on a nursing discussion question and need an explanation and answer to help me learn.
|“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|
|Subjective||Fever and chills, Lost appetite Flatulence No mucus or blood on stool|
|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.|
|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.|
|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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