Clinical Case Presentation

Clinical Case Presentation

You can use the same case, but I need to add in the Soap NoteThe pathophysiology of the Diagnostic

students must post one interesting case that he/she has seen in the clinical setting via Discussion Board in the online part of this course. The case should be an unusual diagnosis, or a complex case that required in-depth evaluation on the student’s part. The case should be posted in the SOAP format, with references for the patient diagnosis, differential diagnoses (there should be at least 3), and the treatment plan. Notes will be graded as “pass/fail”. In order to receive grade points for SOAP notes, the notes must be approved by the deadlines specified on the course assignments page. The student will lose the opportunity for points on any SOAP notes not approved by the specified deadlines. The posting does not have to be written in APA format, but should be written with correct spelling and grammar. References should be in APA format. The selected references should reflect current evidence – dated within the past 5 years. See rubric in the syllabus section ..

clinical Case

CC: “Abdominal pain”

HPI: This is LR 57 y/o male Hispanic, refer abdominal pain in LLQ that started today at early in the morning, moderate intensity that radiated throughout the four quadrants, no nausea or vomiting,

Current medications: none

SH: Denies use drugs, tobacco or alcohol

Allergies: Shellfish, Iodine

ROS:

CONSTITUTIONAL: No fever, weight loss or chills

NEUROLOGIC: Denies changes in LOC.

HEENT: Denies any head injury, or change in LOC. Denies any changes in vision, diplopia or blurred vision. Denies pain in the ears. Denies loss of hearing or drainage. Denies nasal drainage, congestion. Denies throat or neck pain, hoarseness, difficulty swallowing.

Respiratory: Denies any SOB, congestion, or production of sputum.

Cardiovascular: Denies history of cardiac disease, abnormal EKG or chest pain. Denies dizziness or fatigue.

Gastrointestinal:Abdominal pain or discomfort LLQ, Denies flatulence, nausea, or vomiting.

BIOMETRICS & VS: T 98 F (oral) HR: 78 bmp RR 20 bmp

BP: 140/89 SPO2: 100 H: 5 f.9 in W: 169 Lb BMI: 25

Labs: CBC,and FOBT indicated, U/S of abdomen w/o contrast

Physical exam

GEN: No acute distress, alert, awake, and oriented times 4 (name, place, time, purpose), well nourished.

HEENT: mucous membranes moist, no pallor,no icterus

Cardiovascular: S1 and S2 RRR, no murmurs, no rubs

RESP: Clear to auscultation bilaterally, no rales/rhonchi/wheezes, no fremitus

ABD: Normal , no pulsate masses, bowel sounds present in four quadrants, Soft to touch, non distended, no rebound or guarding, no hepatosplenomegaly.

NEUROLOGIC: Cranial Nerve II through XII intact, no focal deficit. Sensation intact to bilateral upper and lower extremities. Bilateral

SKIN: Intact, no rashes, no lesions, no erythema,no dehydration sings.

GU: no inguinal hernia, no inguinal lymphadenopathy

Diagnosis:

Ulcerative Colitis

Differential Diagnosis:

Bowel obstruction : the abdominal pain occurs when the passage of normal GI contents is blocked. This usually occurs as a result of post-operative complications or simply constipation, nausea and vomiting are remarkable.

Mesenteric ischemia of the smoll intestine : The patient usually presents with rapid onset of severe periumbilical abdominal pain that is out of proportion tophysical exam findings in addition to nausea and vomiting.

Plan

mesalamine 0.5g 1 suppository rectal every 8 hours.

Teaching:

Eat small amounts of food throughout the day. Drink plenty of water (frequent consumption of small amounts throughout the day). Avoid foods rich in fiber (bran, beans, nuts, seeds and popcorn). Avoid fatty, greasy or fried foods and sauces (butter, margarine and thick cream)

Referrals: GI

Follow Up: 1 week

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