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week 4 discussion

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
(CC) 

“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
• AUSCULTATION: bowel sounds (BS) are normal in all four quadrants, no bruits noted
• PALPATION: on palpation, abdomen is tender to touch in four quadrants; tenderness noted on light palpation, deep palpation reveals no masses, spleen and liver unremarkable
• PERCUSSION: tympany heard in all quadrants, no dullness noted in abdominal area

GU

• EXTERNAL: mature hair distribution; no external lesions on labia
• INTROITUS: slight green-gray discharge, no lesions
• VAGINAL: normal rugae; moderate amount of green discharge on vaginal walls
• CERVIX: nulliparous os with small amount of purulent discharge from os with positive cervical motion tenderness (CMT)
• UTERUS: ante-flexed, normal size, shape, and position
• ADNEXA: bilateral tenderness with fullness; both ovaries without masses
• RECTAL: deferred
• VAGINAL DISCHARGE: green in color

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. 

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