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?
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