For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases.
Case 2 |
|
Chief Complaint |
“I have pain in my belly” |
History of Present Illness (HPI) |
A 25-year-old female presents to the emergency room (ER) with complaints of severe abdominal pain for 2 weeks . The pain is sharp and crampy It hurts if I run, sit down hard, or if I have sex |
PMH |
Patient denies |
PSH |
|
Drug Hx |
Birth control |
Allergies |
NKA |
Subjective |
Nausea and vomiting, Last menstrual period 5 days ago, New sexual partner about 2 months ago, No condoms, he hates them No pain, blood or difficulty with urination |
PE |
B/P 138/90; temperature 99°F; (RR) 20; (HR) 110, regular; oxygen saturation (PO2) 96%; pain 5/10 |
General |
acute distress and severe pain |
HEENT |
Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition. Piercing in her right nostril and lower lip. |
Neck |
|
Lungs |
CTA AP&L |
Card |
S1S2 without rub or gallop |
Abd |
• INSPECTION: no masses or thrills noted; no discoloration and skin is warm to; no tattoos or piercings; abdomen is nondistended and round |
GU |
• EXTERNAL: mature hair distribution; no external lesions on labia |
Ext |
no cyanosis, clubbing or edema |
Integument |
intact without lesions masses or rashes |
Neuro |
No obvious deficits and CN grossly intact II-XII |
Once you received your case number, answer the following questions:
1.
What other subjective data would you obtain?
2.
What other objective findings would you look for?
3.
What diagnostic exams do you want to order?
4.
Name 3 differential diagnoses based on this patient presenting symptoms?
5.
Give rationales for your each differential diagnosis.
Submission Instructions:
· Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.