SuperIronWombat4870
NU632 Unit 12 Discussion Case C.C. “I’m so thirst all the time.”…
NU632 Unit 12 Discussion Case C.C. “I’m so thirst all the time.”
HPI: 14 y.o. F presents to clinic with grandfather for what she believes is dehydration. She reports
symptoms started a week ago with constantly being thirst. She noticed that she was going to the
bathroom more than normal too, but she thought it was because she was drinking more. She denies
burning or blood with urination. She is having some abdominal pain but reports more like cramping.
She has also been experiencing some nausea but no vomiting. Denies diarrhea, fever or chills. She is
currently drinking a bottle of Gatorade in office. Grandfather reports her being sick a few weeks ago but
she hasn’t gotten better since then. He reports her looking tired.
Allergies: None.
Current Mediation: None.
Up to date on all immunizations with the exception of flu vaccine.
CAD.
Exercise & Diet: Patient does have a regular exercise routine. Eats healthy variety of foods. Safety Measures: Wears seat belt. No firearms in the home.
ROS:
Health Maintenance:
Family History: Mother – HTN, diabetes. Father – No medical history. Maternal grandfather deceased at
61 due to heart attack and maternal grandmother has diabetes and HTN. Paternal grandfather HTN,
Social History: Denies drug, ETOH or illicit drug use. She is a high school freshman. She is unemployed.
She is not sexually active.
General: Overall, she reports feeling okay, has reported some weight loss but no changes in appetite.
Has had increase thirst. HEENT: Denies headaches, sinus problems, dental problems, oral lesions,
hearing loss or changes, nasal congestion. Denies visual changes, diplopia, and dry eyes. Denies ear pain,
changes in hearing, tinnitus. Denies sore throat, difficulty swallowing, dental pain. Denies neck pain or
stiffness.
Denies
any history of a heart murmur, chest pain, palpitations, dyspnea, activity intolerance,
varicose veins, or edema.
Denies
cough, SOB on exertion, difficulty breathing, wheezing. GI: Denies,
vomiting, dysphagia, loss of appetite, bloating, diarrhea, or change in bowel habits. Has had some
abdominal cramping with nausea. Has not achieved menarche.
GU: Denies sexually active. Denies dysuria but is having urinary frequency.
Hem: Denies bruising or bleeds easily or history of any blood transfusions.
MSK: Patient denies joint pain, swelling, muscle pain or cramps, neck pain or stiffness, or changes in
ROM.
Neuro: Denies weakness, numbness, tingling, memory difficulties, involuntary movements or tremors
Endo: Denies cold or heat intolerance, having increase in thirst and some weight loss (about 10 lbs).
Psych: Patient denies mood changes, anxiety, depression, nervousness, insomnia, suicidal thoughts, and
exposure to violence, or excessive anger.
Objective:
Physical Examination (PE):
VS: BP: 102/60, HR: 76, RR: 18, Temp 98.5, weight: 109, height: 63inches
Gen: General Appearance: Affect and facial expression appropriate to situation, patient well-nourished
and appears stated age. No acute distress noted. Ambulating without assistance.
Skin: Skin warm, dry and intact. No lesions present. Skin tenting.
HEENT: Skull round with symmetrical protuberances, nontender upon palpation, hair evenly
distribution, and scalp clean and free of lesions. Conjunctivae pink. Pupils are PERRL, 3 mm bilaterally.
Sunken eyes. Extraocular movements intact. Ears appearance within normal limits. Hearing is intact.
Nose: appearance of nose normal with no mucous, inflammation or lesions present. Nares patent.
Septum is midline. Mouth: pink, dry, tacky mucous membranes. No missing or decayed teeth. Neck: Had
a supple and no lymphadenopathy CV: S1, S2. Regular rate and rhythm. Respiratory: Even and
unlabored. Clear to auscultation bilaterally without wheezes, rales, or rhonchi.
Abd: soft, flat, nontender without masses or hepatosplenomegaly. Bowel sounds active x 4. No bruits.
GU: No bladder tenderness upon palpation, no distention noted. No CVA tenderness.
PV: No edema. Capillary refill < 2 sec bilaterally. MSK: Normal ROM, joint stability normal in all extremities, no tenderness to palpation. No scoliosis noted. Neuro: Grossly alert and oriented x3, communication ability within normal limits, attention and concentration normal. Sensation intact to light touch, gait within normal limits Psych: Judgment and insight intact, rate of thoughts normal and logical. Pleasant, calm, and cooperative. Patient appears to be happy/content. The first part of the discussion board is to identify all pertinent positive and negative information. What other questions may you want to ask the patient? How will you address these findings? Now make a plan utilizing clinical practice guidelines for the priority diagnosis.
