Skip to Main Content

PATIENT PRESENTATION

Chief Complaint

“I can’t stop going to the bathroom, and I’m starting to get dehydrated.”

History of Present Illness

JB is a 32-year-old Caucasian male who presents to his primary care physician with complaints of bloody diarrhea approximately 5 times per day, abdominal pain, and nausea for the past 4 days. He also complains of intermittent fevers and dry mouth. He states that he recently traveled to India on a medical mission trip with other students in his medical school program. Of note, JB did not receive any vaccinations or medications prior to travel and has not received antibiotics in the past 5 years. He is up-to-date on all routine childhood vaccines.

Past Medical History

Seasonal allergies, depression, anxiety

Surgical History

Tonsillectomy and adenoidectomy in primary school

Family History

Father has hyperlipidemia and type 2 diabetes; mother has no significant medical history

Social History

Student in his third year of medical school, married, lives with wife, and drinks alcohol occasionally. Reports no illicit drug or tobacco use

Allergies

Ciprofloxacin (hives/shortness of breath)

Home Medications

Cetirizine 10 mg PO daily

Sertraline 100 mg PO daily

Physical Examination

Vital Signs

Temp 102.3°F, P 89, RR 24 breaths per minute, BP 110/69 mm Hg, pO2 94%, Ht 6′2″, Wt 89 kg

General

Male with dizziness and in mild distress

HEENT

Normocephalic, PERRLA, EOMI, dry mucous membranes and conjunctiva, fair dentition

Pulmonary

Normal breath sounds

Cardiovascular

NSR, no m/r/g

Abdomen

Slightly distended, positive for abdominal pain, bowel sounds hyperactive

Genitourinary

Normal male genitalia, no complaints of dysuria or hematuria

Neurology

Oriented to place and person

Extremities

Negative for pain or rash

Back

Negative for back pain

Laboratory Findings

Favorite Table | Download (.pdf) | Print

Na =148 mEq/L

K = 3.0 mEq/L

Cl = 107 mEq/L

CO2 = 24 mEq/L

BUN = 32 mg/dL

SCr = 1.5 mg/dL

Glu = 90 mg/dL

Ca = 8.4 mg/dL

Mg = 1.5 mg/dL

Phos = 4.8 mg/dL

Hgb = 15.0 g/dL

Hct = 50%

Plt = 200 × 103/mm3

WBC = 15 × 103 mm3

AST = 18 IU/L

ALT = 20 ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.