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Published byStanley Williams Modified over 9 years ago
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Clinical Integration: Emergency Medicine Lucero, Lee, Macalintal, Magallanes, Maningas, Ombao, and Pacifico
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Subjective 30 yo F CC: acute diarrhea (bloody watery stools) HPI “feeling hot” Persistent choking sensation Unrelieved by drinking water (+) nausea, vomiting (+) crampy abdominal pain (+) pallor, feeling faint
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Review of Systems (-) skin lesions, pruritus (-) eye redness, itchiness, discharges and lacrimation (+) nasal stuffiness (+) slight dyspnea (-) wheezing
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Past Medical History (+) asthma Rx: salbutamol inhaler (+) allergy to peanuts (+) atopy 1 yr PTA: appendectomy OB-GYN History delayed menstruation
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Objective awake, confused, and stretcher-borne hypotensive Weak extremitiy pulses tachycardic, tachypneic, and afebrile (+) flushed skin (-) rashes (+) pale palpebral conjunctiva (+) watery nasal discharge (-)FB inside the oropharynx
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Objective (+) bilaterally decreased breath sounds (+) appendectomy scar (+) hyperactive bowel sounds (+) slight lower abdominal tenderness (+) reddish stool on DE
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Neurologic Examination awake but confused GCS is 12
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Salient Features (+) acute diarrhea “feeling hot” Persistent choking sensation (+) nausea, vomiting (+) crampy abdominal pain (+) pallor, feeling faint (-) skin lesions, pruritus (-) eye redness, itchiness, discharges and lacrimation (+) nasal stuffiness (+) slight dyspnea (-) wheezing (+) asthma (+) allergy to peanuts (+) atopy 1 yr PTA: appendectomy delayed menstruation upon consult awake, confused, and stretcher- borne Hypotensive, tachycardic, tachypneic, and afebrile (+) flushed skin (-) rashes (+) pale palpebral conjunctiva (+) watery nasal discharge (-)FB inside the oropharynx (+) bilaterally decreased breath sounds (+) appendectomy scar (+) hyperactive bowel sounds (+) slight lower abdominal tenderness (+) reddish stool on DE awake but confused GCS is 12
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