Identify the different part of the case by placing a comment on the items like in case #1.

Send
the edited file to gracealunan@gmail.com with a filename change to case_surname example:
Case_Alunan. Thanks!

Example:
Case #1

Patient PS, a 60 year old man presented to the ER with a chief complaint of having several
episodes of diarrhea, not being able to keep anything down and feeling awful. Two days prior to
consult the patient experienced severe nausea that occurred about 6 hours after eating out at a
Chinese restaurant buffet. He had eaten a variety of traditional Chinese dishes but had no
consumption of alcoholic beverage or milk/dairy product. He took 2tbsp of Maalox at that time.
The nausea persisted, and subsequently vomited "several times" with some relief. As the
evening progressed, he still felt "awful" and took 2 Prilosec OTC tablet to settle his stomach. He
began to feel achy and warm, and his temperature at that time was 38.2 C. He has continued to
have nausea and vomiting and mild fever. He has not tolerated solid food nor has been able to
keep down small amount of fluid. One day prior to consult, he had 6-8 liquid stool along with
crampy abdominal pain. He has not noticed any blood or mucus in the bowel movement.The
patient is a known hypertensive for 6 years, hyperlipidemic for 3 years, had GERD for 10 years
and was diagnosed in 2004 to have gastric ulcer.

He was a smoker with 30 pack years history and quit 3 years ago, an occasional alcoholic
beverage drinker. He denies illicit drug use. He has been married for 20 years and works as a
local bus driver. His family history is unrelated

He is (+) for lightheadedness upon standing, denies headache, sore throat, ear pain, or nasal
discharge. Denies coughing or constipation. Frequent bout of nausea. Frequent loose stools
associated with significant cramping. Decreased urination; no pain upon urination. Complains of
generalized fatigue, mild aching, feels like his heart is pounding.

He is on maintenance of HCTZ 25mg PO daily for 6 years, Atorvastatin 10mg PO at bedtime for
3 years and Omeprazole 20mg PO daily. Patient is allergic to Morphine and pollen.
He patient is a white man, appears ill and in moderate distress. Vital signs were recorded as
follows BP 135/92 mmHg, Pulse rate of 80bpm, RR 16, T 38.2C, weight of 95kg and height of
5`9". Skin is warm to touch, fair skin tugor (mild tenting noted). Dry mucous, non-erythematous
TMs, PERRLA, some AV nicking, slight erythema in throat. Without node masses,
lymphadenopathy and thyromegaly.

Case 2
Patient MC, a 54 year old woman presented to the clinic due to increasing stomach pain for
several day. Her last bowel movement was 6 days ago. She began "not feeling well" 4 days ago
with some mild chills, bloating, decreased appetite and fatigue. She has no fever, nausea and
vomiting, chest pain or shortness of breath. She reports that yesterday, when her cramping was
at its worst, she used magnesium citrate, Miralax and fleet enema but still no bowel movement.
She states that she typically has daily bowel movement, with no straining and spends less than
10 minutes, with less effort, having a bowel movement. She reports having similar episode
approximately 1 year ago; however, at that time her symptoms responded to magnesium citrate
and Miralax. She does not use stool softener on a regular basis.

She has a history of Asthma, hypertension, depression and Iron Deficiency Anemia. Her mother
is a 75years old and is healthy. While her father died at the age of 54 due to lung cancer. She
has three brothers and 2 sisters, one of her brothers has viral hepatitis. She is married and
works as a social worker. She is a smoker with 20 pack years. She is a non-alcoholic beverage
drinker and does not use illicit drugs. She is (+) for constipation, lower abdominal fullness and
fatigue she is (-) for nausea and vomiting, shortness of breath, chest pain and fever/chills. She
has been taking the following medications Diltiazem CR 240mg PO daily, Digoxin 0.25mg PO
daily and Atenolol 25mg PO daily.

She is a pleasant woman in mild distress; appears tired with VS of; BP 122/60mmHg, P 57; RR
16, T 36.2C, Wt 112.4kg and 5`5". Her skin is normal skin turgor and color. Lungs has normal
breath sounds, no crackles. Abdomen is soft obese, tender and with decreased bowel sound,
stool palpable on left side.