27 Dec Gastrointestinal: See HPI

MSN610 Diagnostic Reasoning and Advanced Physical Assessment

Module 5 Discussion

Case Study 5

CC: J.D. is a 32 year old male presents to your office for a complete physical exam as a new patient. He c/o intermittent episodes of diarrhea, abdominal discomfort, bloating and occasional constipation.

HPI: J.D. states he often eats a meal and within 10 minutes, he feels bloated and “gassy”. He frequently has periods of nausea, urgent watery diarrhea. This is embarrassing for him as he is not always near a bathroom. This has become progressively worse over the last years and occurs almost daily. He first realized he was having bowel problems when he was in high school when he played on the football team. Diarrhea always seemed to get worse on game day. He denies vomiting or laxative use.

PMH: No hospitalizations or surgeries. His childhood immunizations were all completed and he had a tetanus booster 5 years ago. Only health problem has been his abdominal bloating and “bowel problems”. He was treated for strep throat and a sinus infection 5 years ago with Amoxicillin.

FH: Relationship Mortality Age Health Problems

Mother Alive 54 None

Father Alive 56 Arthritis

MGM Alive 70 HTN, Rheumatoid Arthritis, HLN

PGM Alive 66 Breast CA, Pacemaker

PGF Alive 67 None

MGF Deceased 65 CVA

SH: He is a graduate student at the university studying Psychology. He lives in an apartment with his girlfriend.

He drank heavily in high school, but may have 1 glass of wine weekly. Denies smoking cigs/marijuana or IV drug use. He exercises regularly but his diet is “awful” and depends on how hectic his schedule is. He is currently working full time as a bank teller.

Meds: None Allergies: None

ROS:

General: Fair appetite with no weight loss, Denies fatigue, fever, chills, blood transfusion

Skin: Denies rashes, lesions, scars

HEENT: Denies dizziness, headaches, head trauma, vision or hearing difficulties, Sees dentist annually, Denies allergies, nasal congestion, sinus problems, dysphagia

Neck: Denies lumps, pain, stiffness

Cardiac: Denies chest pain, dyspnea on exertion, palpitations

Resp: Denies dyspnea, cough, wheezing

Gastrointestinal: See HPI

Genitourinary: Denies dysuria, frequency, hematuria, penile discharge, heterosexual but libido is low as he frequently just does not feel well.

Musculoskeletal: Denies joint pain, swelling, arthritis, myalgia

Endocrine: Denies skin or hair changes, temperature intolerances, excessive thirst or urination

Neurological: Denies weakness, seizures,

Psychological: Denies depression, but admits he sometimes gets “anxious” with graduate school and work.

Nutritional: Admits he eats 1 meal/day usually in the evening when “life has quieted down”. This meal consists of some meat/potato. Salads causes bloating. Snacks can cause cramping and diarrhea in the afternoon-so I just don’t eat. Milk products do not seem to bother him.

Physical Exam:

Vital Signs: Temperature 98 Pulse: 76 b/min Resp: 16/mi BP: 120/80 HT: 5’11 WT: 174 BMI: _____

General Appearance: Well developed, well nourished, appropriately groomed and appears his stated age

Skin: Smooth, soft, w/o lesions, rashes, scars. Tattoo of an eagle on his chest.

HEENT: Normocephalic with evenly distributed hair. No redness or lesions of his eyes, extraocular movements (EOM) intact.

Ophthalmic Exam: Red reflex intact bilaterally. Optic Disc is round creamy yellow with clear margins. Retinal vessels are bright red without exudate, edema, and wool spots. Macula is positive for foveal light reflex.

MSN610 Diagnostic Reasoning and Advanced Physical Assessment

Module 6 Discussion

Case Study 6

CC: 85 year old female presents to your exam room with “memory loss”

HPI: J.B. is brought in with her son who states his mom is forgetting to pay her bills over the last 4 months and “gets lost” in her own home. J.B. admits she sometimes gets “forgetful”. Her previous PCP retired 6 months ago and they have no medical records with them.

PMH: Total Abdominal Hysterectomy 20 years ago. G3P2 1 Miscarriage. No other surgeries or hospitalizations. Treated for HTN, A-fib

Medications: HCTZ 25 mg daily Allergies: None

Digoxin 0.25 mg daily

Coumadin 1 mg daily

Multivitamin daily

FH: Relationship Mortality Age Health Problems

Mother Deceased 54 Diabetes Mellitus II

Father Deceased 75 CAD

Daughter Deceased 20 MVA

Son Alive 45 None

ROS:

General: Denies weight loss, fatigue until the last 3 days, generally eats well

Skin: Denies birthmarks, scars, no previous rashes

HEENT: Denies dizziness, head trauma, vision trouble, does wear glasses, Had cataract surgery in L eye , denies swallowing problems, nasal congestion,

Neck: Denies lumps, pain, stiffness

Resp: Denies dyspnea or pain, cough, wheezing

Cardiac: Denies chest pain, or edema of extremities, Has had an irregular heart rhythm “for years”

Gastrointestinal: Denies nausea, vomiting, diarrhea or abdominal pain

Genitourinary: Denies hematuria, dysuria, or odor

Musculoskeletal: Denies back pains, Admits to knee pain with difficulty walking

Neurological: Denies seizures, limb weakness, headaches, loss of consciousness

Psychological: Denies depression/anxiety. No suicidal/homicidal ideations.

She likes to color and work on puzzles but sometimes “I loose pieces” that makes me angr