Medical Assessment and Diagnoses.
ANSWER
Subjective Data: In addition to the information provided in the cases, you would want to obtain more detailed subjective data from the patients. This may include:
- Medical history: Details about any pre-existing medical conditions, chronic illnesses, surgeries, or hospitalizations.
- Medication history: A complete list of current medications and any recent changes.
- Family history: Information about any family history of thyroid disorders, gastrointestinal disorders, or other relevant medical conditions.
- Social history: Information about the patient’s lifestyle, including dietary habits, alcohol or substance use, and sexual history.
- Review of systems: Ask about any other symptoms the patient may be experiencing, even if they do not seem directly related to the chief complaint.
Objective Findings: In addition to the objective data provided in the cases, you would want to conduct a thorough physical examination to gather more objective information. This may include:
- Detailed abdominal examination: Palpation, percussion, and auscultation to assess for tenderness, masses, organomegaly, and bowel sounds.
- Thyroid examination: Further assessment of thyroid gland size, consistency, and any associated nodules.
- Pelvic examination: To evaluate for any abnormalities in the pelvic area, including the cervix, uterus, adnexa, and any vaginal discharge.
- Cardiovascular examination: To assess for any heart abnormalities.
- Dermatological examination: To check for any skin changes or rashes that may be relevant to the case.
Diagnostic Exams: Based on the patient’s presentation and physical examination, you may want to order the following diagnostic exams:
- Stool analysis: To assess for the presence of infectious agents, blood, or other abnormalities in the stool.
- Complete blood count (CBC): To check for signs of infection, anemia, or other blood-related issues.
- Thyroid function tests: To evaluate thyroid hormone levels, including TSH, T3, and T4.
- Abdominal imaging: Such as ultrasound or CT scan, to visualize the abdominal organs and assess for any structural abnormalities.
- Pelvic ultrasound: To further evaluate the pelvic organs and any potential gynecological issues.
Differential Diagnoses: Based on the patient’s presenting symptoms and additional information, here are three possible differential diagnoses for each case:
Case 1 (Frequent and watery bowel movements):
- Acute Gastroenteritis: Due to recent onset of diarrhea, fever, and chills, infectious gastroenteritis is a likely differential diagnosis.
- Irritable Bowel Syndrome (IBS): Considered if no infectious cause is found, especially if symptoms are recurrent and associated with stress.
- Food Intolerance or Allergy: Some individuals may experience loose stools due to specific food intolerances or allergies.
Case 2 (Abdominal pain):
- Pelvic Inflammatory Disease (PID): Given the severe abdominal pain and green vaginal discharge, PID could be a possible diagnosis, especially if there is cervical motion tenderness.
- Ovarian Cyst or Torsion: Ovarian conditions can cause sharp abdominal pain, and an ultrasound may help confirm this.
- Endometriosis: This condition can lead to chronic pelvic pain, especially during menstruation or sexual activity.
Case 3 (Neck swelling):
- Thyroid Disorder (e.g., Graves’ Disease): Given the diffuse thyroid enlargement and tachycardia, a thyroid disorder could be a possible diagnosis.
- Thyroid Nodule or Goiter: Structural thyroid abnormalities may result in neck swelling.
- Lymphadenopathy: Swollen lymph nodes in the neck could be due to various causes, including infections or malignancies.
Rationales:
- The differential diagnoses are based on the chief complaint and additional symptoms and findings to cover a range of possible underlying causes.
- Each differential diagnosis aligns with the patient’s age, sex, and relevant medical history, which may predispose them to certain conditions.
- Further diagnostic tests are required to confirm or rule out these potential diagnoses, allowing for a more accurate assessment of the patient’s condition and appropriate treatment planning.
Question Description
I’m working on a health & medical discussion question and need the explanation and answer to help me learn.
Case 1
Case 2Case 3Chief Complaint
(CC) “I am here today due to frequent and watery bowel movements”“I have pain in my belly”“neck swelling”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 hoursA 25-year-old female presents to the emergency room (ER) with complaints of severe abdominal pain for 2 weeks . The pain is sharp and crampy It hurts if I run, sit down hard, or if I have sexA 42-year-old African American female who refers that she has been noticing slow and progressive swelling on her neck for about a year. Also she stated she has lost weight without any food restriction PMHNo contributory Patient deniesPatient denies PSHAppendectomy at the age of 14 Surgical removal of benign left breast nodule 2 years agoDrug Hx
No medsBirth controlNo medication at the timeAllergiesPenicillinNKANKASubjectiveFever and chills, Lost appetite Flatulence No mucus or blood on stoolsNausea and vomiting, Last menstrual period 5 days ago, New sexual partner about 2 months ago, No condoms, he hates them No pain, blood or difficulty with urinationMild difficult to shallow, Neck feels tight, Pt states she feels PalpitationsObjective Data PEB/P 188/96; Pulse 89; RR 16; Temp 99.0; Ht 5,6; wt 110; BMI 17.8B/P 138/90; temperature 99°F; (RR) 20; (HR) 110, regular; oxygen saturation (PO2) 96%; pain 5/10 B/P 158/90; Pulse 102; RR 20; Temp 99.2; Ht 5,4; wt 114; BMI 19.6 Generalwell-developed female in no acute distress, appears slightly fatiguedacute distress and severe pain42-year-old female appears thin. She is anxious – pacing in the room and fidgeting, but in no acute distress. HEENTAtraumatic, normocephalic, PERRLA, EOMI, arcus senilus bilaterally, conjunctiva and sclera clear, nares patent, nasopharynx clear, edentulous.
Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition. Piercing in her right nostril and lower lip.
Bulging eyes NeckSuppleDiffuse enlargement of the thyroid glandLungsCTA AP&L
CTA AP&L
CTA AP&LCardS1S2 without rub or gallopS1S2 without rub or gallopS1S2 without rub, TachycardiaAbdpositive bowel sounds (BS) in all four quadrants; no masses; no organomegaly noted; diffuse, mild, bilateral lower quadrant pain noted Mild diffuse tenderness.
- INSPECTION: no masses or thrills noted; no discoloration and skin is warm to; no tattoos or piercings; abdomen is nondistended and round
• AUSCULTATION: bowel sounds (BS) are normal in all four quadrants, no bruits noted
• PALPATION: on palpation, abdomen is tender to touch in four quadrants; tenderness noted on light palpation, deep palpation reveals no masses, spleen and liver unremarkable
• PERCUSSION: tympany heard in all quadrants, no dullness noted in abdominal area
benign, normoactive bowel sounds x 4GU Non contributory• EXTERNAL: mature hair distribution; no external lesions on labia
• INTROITUS: slight green-gray discharge, no lesions
• VAGINAL: normal rugae; moderate amount of green discharge on vaginal walls
• CERVIX: nulliparous os with small amount of purulent discharge from os with positive cervical motion tenderness (CMT)
• UTERUS: ante-flexed, normal size, shape, and position
• ADNEXA: bilateral tenderness with fullness; both ovaries without masses
• RECTAL: deferred
• VAGINAL DISCHARGE: green in color Non contributoryExtno cyanosis, clubbing or edemano cyanosis, clubbing or edemano cyanosis, clubbing or edemaIntegumentgood skin turgor noted, moist mucous membranesintact without lesions masses or rashesThin skin, Increase moistureNeuroNo obvious deformities, CN grossly intact II-XIINo obvious deficits and CN grossly intact II-XIINo obvious deficits and CN grossly intact II-XII
Once you received your case number, answer the following questions:
- 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.
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