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CC:
HPI:
Onset
Palliative/provoke
Progress
Quality (color, pain, burning, smell, etc.)
Radiation
Site, severity
Timing
Associated symptoms
PMx:
PSHx:
Meds:
ALL: Allergies and reaction
FHx: Family healthy issues
SHx: Alcohol, diet, water, exercise, work,
HCM: up to date on childhood vax, colonoscopy, last primary care visit
ROS: fever, weight change, chills, headache, fatigue, nausea, vomiting, vertigo, flushing, SOB, cough, hemoptysis, palpitations, difficulty sleeping, blood in urine, change in urine habits, change in bowel habits, blood in stool, the color of stool, hematemesis, when do Sx's occur, pain while defecating,
Objective
Vitals
General Appearance
HEENT:
Neck:
Thyroid nodules
JVD
LAD
Chest:
Lungs:
Lungs clear to auscultation and percussion in anterior, posterior, and lateral fields
Heart
Normal S1, S2; no S3, S4; no murmurs, gallops, and rubs
Normal PMI size and location
Abdomen:
Inspect
Ausucltate
Percuss
Palpate
Determine liver size and spleen size through palpation and percussion
Check for friction rubs of spleen and liver
Extremities
Clubbing
Cyanosis
Edema
Rectal
Visual examination for discharge, prolapse, perforations
Fecal occult blood test
Osteopathic
Innominate diagnosis
Restriction in pelvis
Lumbar diagnosis
A
IBS-Diarrhea Predominant
Functional Diarrhea
Celiac
IBD
VIPoma
Carcinoid tumor
Dysfunction in innominate and lumbar regions
Plan
Order a CMP, CBC, CRP level, antibodies against ASCA, p-ANCA, and tTG, endomysial, deamidated gliadin
X-ray abdomen
Pending on if the initial lab results return negative/indeterminate then discuss the potential of a colonoscopy in the near future
Perform lumbar MET and pelvic diaphragm release
Prescribe bulk-forming agent, psyllium, and if symptoms do not improve then discontinue and instead prescribe loperamide
Check back with the patient in two weeks to determine if symptoms have improved
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