NKU MSN610 Module 5 Discussion Latest 2020 March

MSN610 Diagnostic Reasoning and Advanced Physical Assessment

Module 5 Discussion

Case Study 5

CC: J.D. is a 32 year old male presents to your office for a complete physical exam as a new patient. He c/o intermittent episodes of diarrhea, abdominal discomfort, bloating and occasional constipation.

HPI: J.D. states he often eats a meal and within 10 minutes, he feels bloated and “gassy”. He frequently has periods of nausea, urgent watery diarrhea. This is embarrassing for him as he is not always near a bathroom. This has become progressively worse over the last years and occurs almost daily. He first realized he was having bowel problems when he was in high school when he played on the football team. Diarrhea always seemed to get worse on game day. He denies vomiting or laxative use.

PMH: No hospitalizations or surgeries. His childhood immunizations were all completed and he had a tetanus booster 5 years ago. Only health problem has been his abdominal bloating and “bowel problems”. He was treated for strep throat and a sinus infection 5 years ago with Amoxicillin.

FH:         Relationship                       Mortality             Age                        Health Problems

                Mother                                                Alive                      54                           None

                Father                                   Alive                      56                           Arthritis

                MGM                                    Alive                      70                           HTN, Rheumatoid Arthritis, HLN

                PGM                                      Alive                      66                           Breast CA, Pacemaker

                PGF                                        Alive                      67                           None

                MGF                                      Deceased            65                           CVA

SH:         He is a graduate student at the university studying Psychology. He lives in an apartment with his girlfriend.

He drank heavily in high school, but may have 1 glass of wine weekly. Denies smoking cigs/marijuana or IV drug use.  He exercises regularly but his diet is “awful” and depends on how hectic his schedule is. He is currently working full time as a bank teller.

Meds: None                                                                                                       Allergies: None

ROS:

General: Fair appetite with no weight loss, Denies fatigue, fever, chills, blood transfusion

Skin: Denies rashes, lesions, scars

HEENT: Denies dizziness, headaches, head trauma, vision or hearing difficulties, Sees dentist annually, Denies allergies, nasal congestion, sinus problems, dysphagia

Neck: Denies lumps, pain, stiffness

Cardiac:  Denies chest pain, dyspnea on exertion, palpitations

Resp:  Denies dyspnea, cough, wheezing

Gastrointestinal:  See HPI

Genitourinary: Denies dysuria, frequency, hematuria, penile discharge, heterosexual but libido is low as he frequently just does not feel well.

Musculoskeletal: Denies joint pain, swelling, arthritis, myalgia

Endocrine: Denies skin or hair changes, temperature intolerances, excessive thirst or urination

Neurological: Denies weakness, seizures,

Psychological: Denies depression, but admits he sometimes gets “anxious” with graduate school and work.

Nutritional: Admits he eats 1 meal/day usually in the evening when “life has quieted down”. This meal consists of some meat/potato. Salads causes bloating. Snacks can cause cramping and diarrhea in the afternoon-so I just don’t eat. Milk products do not seem to bother him.

Physical Exam:

Vital Signs:   Temperature 98       Pulse: 76 b/min      Resp:  16/mi     BP: 120/80     HT: 5’11  WT: 174   BMI: _____

General Appearance:  Well developed, well nourished, appropriately groomed and appears his stated age

Skin: Smooth, soft, w/o lesions, rashes, scars. Tattoo of an eagle on his chest.

HEENT: Normocephalic with evenly distributed hair. No redness or lesions of his eyes, extraocular movements (EOM) intact.

Ophthalmic Exam: Red reflex intact bilaterally. Optic Disc is round creamy yellow with clear margins. Retinal vessels are bright red without exudate, edema, and wool spots. Macula is positive for foveal light reflex.

Otoscopic Exam: No ear discharge, TM grey and intact, crisp cone of light

Nose: patent nasal airways, no exudates, turbinates pink without polyps

Mouth: Good dentition, no lesions, buccal tissue pick, tongue/uvula midline, pharynx unremarkable

Neck: No lymphadenopathy, thyromegaly, Has Full ROM, No JVD

Heart: Regular S1S2 w/o gallops, rubs, or murmurs, PMI @ 5ICS MCL

Lungs: Clear to auscultation bilaterally with equal excursion and normal tactile fremitus

Abdomen: soft, no masses, no HJR, no organomegaly, slight diffuse tenderness with light palpation in lower abdomen

Bowel sounds: hyperactive in 4 quads. Rectum: empty, no masses with normal tone. No hemorrhoids or fissures

Hemoccult: Negative

Genitourinary: No palpable inguinal nodes, circumcised penis without lesions, edema, erythema or discharge. Testes descended without masses or tenderness, negative for inguinal hernia

Peripheral Vascular: No edema with +2 palpable radial, popliteal, pedal pulses bilaterally

Musculoskeletal: FROM of all extremities, no joint swelling, pain in upper or lower extremities

Neurological: CN 2- 12 grossly intact

Psychological: Alert, pleasant but subdued. Cooperative and follows commands. Communicative with focused answers.

What are your pertinent positives and your differential diagnoses?

What diagnostic tests would you proceed to order?

Since this is a new patient, what anticipatory guidance would you recommend?