case studies: Identify a friend, peer, or family member you can interview to collect comprehensive subjective and objective data

case studies: Identify a friend, peer, or family member you can interview to collect comprehensive subjective and objective data, as though…

Case studies

Introduction

Conduct an interview.

Document the subjective and objective findings in a word document and submit to Canvas.  This will be evaluated by the clinical faculty. 

Estimated time to complete: 1 hour

Patient Information:

Solution

Initials: AP Age: 37 Sex: Female Race: Caucasians

CC: “Frequent diarrhea for the past seven days and abdominal pain.”   

HPI: The patient reports persistent diarrhea for the past seven days. The patient experiences a loose, watery, bright yellow, and bloody stool. The patient explains that she also experiences excruciating and psychogenic lower abdominal pain. The patient also experiences nausea and vomiting. The patient stated that she has at least six bowel movements in a day but denied any fever or chills.

The patient scales the pain as 7/10. The pain eases with Liquiprin 15mg.  The patient is also taking Loperamide 4mg orally to control diarrhea.

PMH: Recently diagnosed with hypertension. No record of minor or major surgery. Immunization is up to date.  

Allergy Identification: NKFDA

Medication Reconcilliation:

Liquiprin 15mg orally daily for abdominal pain.

Loperamide 4mg orally daily for diarrhea.

Lisinopril10 mg PO qDay for hypertension.

Socia History: A primary school teacher. Denies use of tobacco and other illicit drugs. Play netball every weekend before a night out with the ‘girls.’

Family History: Single mother of two daughters aged 17 and 10. The daughters are alive and well. The father had diabetes, while the mother has a chronic obstructive pulmonary disease (COPD). The lifestyle changes are managed through medication and lifestyle changes.

Health Promotion: The patient reports eating healthy and exercising thrice weekly.

ROS:

GENERAL:  Denies weight loss, fever, or chills but reports fatigue.

HEENT:  Normocephalic. Eyes:  Use sunglasses since childhood but reports no changes in vision. Ears, Nose, Throat: No hearing loss. Sence of smell and taste are normal. Dry mucus membranes. No sore throat, exudate, or erythema.

SKIN:  Increased skin turgor.

CARDIOVASCULAR: No chest pain, edema, or breathing complications.

RESPIRATORY:  No SOB, cough, or wheezing.

GASTROINTESTINAL:  Denies fever or chills but reports nausea and vomiting. Reports lower abdominal pain and blood in the stool.

MUSCULOSKELETAL:  Reports neck and back pain but deny stiffness.

NEUROLOGICAL: Denies numbness or seizures of any form.

HEMATOLOGIC:  Denies anemia.

LYMPHATICS:   No history of splenectomy. Normal lymph nodes.

PSYCHIATRIC:  No history of depression or mental illness

ENDOCRINOLOGIC:  No sweating, cold, or heat intolerance.

ALLERGIES:  NKDFA

O.

VS: BP: 122/85, P: 73, R: 20, T: 36.60 C, Wt: 164, Ht: 5’7’’

General: Normal mentation but appear fatigued and in discomfort. Properly dressed for the occasion.

HEENT: Head: Normocephalic. EENT: Vision intact. No loss of hearing or smell. Dry mucus membranes. No sore throat.

Extremities: No edema and cyanosis

Neurological: Hyperactive bowel sounds.

Gastrointestinal: Diffused abdominal tenderness, no rebound or guarding.

Diagnostic tests: Critical tests for the patient’s condition include stool test, complete blood count (CBC), urinalysis, molecular testing, and digital rectal exam (Ball et al., 2019). A stool test is vital for testing the presence of ova and parasites to rule out food poisoning. CBC is essential in determining whether an infectious or inflammatory gastrointestinal condition causes the patient’s symptoms.

Urinalysis tests will be crucial in evaluating and eliminating kidney infection systemic diseases, kidney stones, or renal failure as the cause of the patient’s symptoms. Molecular testing is necessary to test the presence of infectious organisms; it is rapid, highly sensitive, and specific.

Reference

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

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case studies: Identify a friend, peer, or family member you can interview to collect comprehensive subjective and objective data
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