Case study: “I have pain in my belly” A 25-year-old female presents to the emerg

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Case study: “I have pain in my belly”

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

Patient denies past medical history

Is on Birth control

Has no known allergies

Subjective data: 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

Physical exam- Objective data: B/P 138/90; temperature 99°F; (RR) 20; (HR) 110, regular; oxygen saturation (PO2) 96%; pain 5/10

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.

Lungs: CTA AP&L

Cardio: S1S2 without rub or gallop

Abdominal: 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

Genitalurinary: 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.

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    A 25-year-old female presents to the emerg appeared first on essaynook.com.

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