“Chronic Diarrhea”

Chief Complaint

  • 21 year old woman presenting to primary care provider with diarrhea

HPI

  • Worsening over past 2 months, now having 6-7 loose bowel movements per day
  • No blood in the stool
  • No other GI symptoms, including nausea, vomiting, or abdominal pain
  • No changes in diet
  • No aggravating or alleviating factors
  • Review of systems positive for intermittent palpitations

PMH

  • Well-controlled asthma on PRN albuterol

Family History

  • Father with COPD
  • Mother with hyperlipidemia, Type 2 diabetes mellitus

Social History

  • No smoking, uses a vape pen daily
  • Drinks 1-2 drinks 3-4 days per week
  • Denies illicit drug use
  • Lives with roommate in apartment
  • No recent travel, no immigration

Vitals

Temp: 36.4° C, BP: 118/64 mmHg, HR: 102 bpm, RR: 12 rpm, SpO2: 98% on room air

Physical Exam

  • Alert, oriented, no acute distress
  • Tachycardic, normal heart rhythm, no murmurs
  • Lungs clear to auscultation bilaterally
  • Abdomen soft, non-tender, non-distended

What would you do next for this patient?

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this: