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“I can’t stop going to the bathroom, and I’m starting to get dehydrated.”
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History of Present Illness
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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.
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Seasonal allergies, depression, anxiety
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Tonsillectomy and adenoidectomy in primary school
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Father has hyperlipidemia and type 2 diabetes; mother has no significant medical history
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Student in his third year of medical school, married, lives with wife, and drinks alcohol occasionally. Reports no illicit drug or tobacco use
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Ciprofloxacin (hives/shortness of breath)
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Cetirizine 10 mg PO daily
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Sertraline 100 mg PO daily
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Temp 102.3°F, P 89, RR 24 breaths per minute, BP 110/69 mm Hg, pO2 94%, Ht 6′2″, Wt 89 kg
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Male with dizziness and in mild distress
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Normocephalic, PERRLA, EOMI, dry mucous membranes and conjunctiva, fair dentition
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Slightly distended, positive for abdominal pain, bowel sounds hyperactive
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Normal male genitalia, no complaints of dysuria or hematuria
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Oriented to place and person
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Negative for pain or rash
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