Name 3 differential diagnoses based on this patient presenting symptoms?
For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases. Your instructor will assign you your case number.
| 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 | ||
| Objective Data | |||
|---|---|---|---|
| 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 |
|
||
| 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:
- What other subjective data would you obtain?
- What other objective findings would you look for?
- What diagnostic exams do you want to order?
- Name 3 differential diagnoses based on this patient presenting symptoms?
- Give rationales for your each differential diagnosis.
Submission Instructions
- Your 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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