iHuman Case Study - Dorothy Markham, 78 yrs Old Female CC: Diarrhea 100% Complete Solutions.

Dorothy Markham

78 y/o

5’3

125 lbs

Vitals

T: 100.76F PO

P: 90

BP: 126/72

RR; 16

O2: 97% RA

CC: Diarrhea

1. How can I help u today? – having a lot of watery diarrhea and stomach has been too

upset. Caretaker at rehab sent her here to see whats wrong. The sent my chart over for

you to review

2. Any other symptoms or concerns we should discuss? – yes appetitie is way off and

having tummy pain. Feel woozy, lightheaded when standing. Feel worn out

3. When did ur diarrhea start – 2 days ago

4. What are the events surrounding the start of ur diarrhea – don’t know

5. How often do u have diarrhea like this - never

6. What tx have u had for ur diarrhea – none

7. Is there any blood in ur stool or with BM – no

8. Do u have black tar-like or foul smelling stool – no

9. How often do u feel that u need to move ur bowels – normally 2x/day. But when

diarrhea started it happened 2x first night, 5x yesterday, and already 2x this AM

10. When did ur abd pain start - when diarrhea did

11. Does anything make the abd pain better or worse – taking it easy and resting makes

better. A little better once get off toilet

12. What does the pain/discomfort in your abd feel like? – crampy

13. Where more precisely is your abd pain – all over belly

14. Do u have any abd bloating? – yes.

15. How severe (1-10) is your abd pain – 6 at its worse

16. How long does the pain in your abdomen last? – comes just before diarrhea, then feels

better after a episode, so not too long

17. Do you have any N/V? – some nausea

18. Have u been in contact w other sick ppl – no

19. Have u been having fevers – don’t know but feel warm

20. Are u taking OTC/herbal meds – baby ASA and calcium with vitamin D

21. Any new or recent change in ur meds – abx 1 week ago

22. When did u last take ur meds? – this AM

23. Do u have any allergies, meds, foods, latex - no

24. ROS: do u have any of the following fatigue, difficulty sleeping – yes tired

25. ROS: headaches that don’t go away with ASA or Tylenol – no

26. ROS: chest pain or pressure – no

27. ROS: SOB, wheezing, diff breathing – no

28. ROS: when u urinate, have u noticed pain, buring, blood etc – had some of that when I

had infection a week ago. Has gone away now

29. ROS: problems w muscle or joint pain – no

30. ROS: dizziness, fainting, spinning room etc – feels lightheaded

Physical Exam:

- Skin: tenting present on back of hand. No rash, pallor, or icterus

- Cap refill nails: abnormal. Blanch times are > 2 sec

- Mouth/pharynx: dry mucous membranes & dry furrowed tounge

- Abdomen: pain upon palpation. Mild diffuse tenderness

- Neuro MMSE: not orientated to date or time

- Orthostatic BP: 106/60  “I feel funny can I please sit”