CASE STUDY #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 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. 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 Then 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. -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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