Exam (elaborations)
CASE STUDY FOR A 18 OLD PATIENT REASON FOR ENCOUNTER VOMITING AND DIARRHEA
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CASE STUDY FOR A 18 OLD PATIENT REASON FOR ENCOUNTER VOMITING AND DIARRHEA
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Patient Overview:• Age: 18 months
• Height: 2' 8" (81 cm)
• Weight: 26.0 lb (11.8 kg)
• Chief Complaint: Vomiting and diarrhea
• Reason for Encounter: Vomiting and diarrhea
•
,Subjective:
CC (chief complaint): Vomiting and diarrhea
HPI: - is a 18-month-old female who presents today with
her mother with complaints of vomiting and diarrhea times
2 days. Sister recently had similar symptoms. Her mother
reports that - has vomited 4-5 times daily for the
past two days and had 3-4 episodes of liquid diarrhea
daily for the past two days. Vomit is liquid with some
partially digested food. Diarrhea is liquid. Denies
coffee-ground emesis or blood in stool or vomit. No
fever, cough, decreased activity. The mother does
report concerns over decreased appetite. Had been
taking Pedialyte and tolerating small amounts of
, Pedialyte and milk. Physical exam without signs of
dehydration, abdominal pain, or rebound tenderness.
1. Asked:
1. How can I help her today?
2. When did her nausea and/or vomiting start?
3. What are the events surrounding the start of her
nausea and/or vomiting?
4. Does anything make her nausea and/or vomiting
better or worse?
5. Does she have any pain or other symptoms
associated with her nausea and/or vomiting?
6. How severe is her nausea and/or vomiting?
7. Has she vomited so forcefully that the vomit went to
the other side of the room?
8. Do you have any pain in your abdomen?
9. Does she have diarrhea?
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