For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases.
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 during intercourse and urination” | ||
| History of Present Illness (HPI) | A 19-year-old female reports to you that she has “sores” on and in her vagina for the last three months. | ||
| Drug Hx | She tries to practice safe sex but has a steady boyfriend and figures she doesn’t need to be so careful since she is on the birth control pill | ||
| Family Hx | |||
| Subjective |
states “I have sores and bumps on the inner creases of my thighs and pelvic area”. “There is yellowish discharge from the sores that comes and goes” | ||
| Objective Data | |||
|---|---|---|---|
| VS | temperature: 100.2°F; pulse 92; respirations 18; BP 122/78; weight 156 lbs, 25 lbs overweight; height 5′3″ | ||
| General | patient appears to have good hygiene; minimal makeup, pierced ears, no tattoos; well nourished (slightly overweight); no obvious distress noted | ||
| HEENT | Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition. Piercing in her right nostril and lower lip. | ||
| Lungs | within normal limits, appropriate lung sounds auscultated, clear and equal bilaterally | ||
| Card | S1S2 without rub or gallop | ||
| Breast |
|
||
| Lymph | Inguinal Lymph nodes: tenderness bilaterally, numerous, 1 cm in size | ||
| Abd | tender during palpation; the left lower quadrant was very tender during palpation; patient denies nausea or vomiting | ||
| GU | labia major and minor: numerous ulcerations, too many to count; some ulcerations enter the vaginal introitus; no ulcerations in the vagina mucosa; cervix is clear, some greenish discharge; bimanual exam reveals tenderness in left lower quadrant; able to palpate the left ovary; unable to palpate the right ovary; no tenderness; uterus is normal in size, slight tenderness with cervical mobility | ||
| Integument | |||
| MS | Muscles are smooth, firm, symmetrical. Full ROM. No pain or tenderness on palpation. | ||
| 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.
- What teachings will you provide?
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