Discussion
Chloe21
Discussion5AdvHealthassessment.docxDiscussion Module 5
Class: Nur 504 Advanced Health Assessment.
Gastrointestinal & Endocrine
For this Discussion, you will take on the role of a clinician who is building a health history for Case # 2.
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Case 2 |
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Chief Complaint (CC) |
“I have pain in my belly” |
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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 |
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PMH |
Patient denies |
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PSH |
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Drug Hx |
Birth control |
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Allergies |
NKA |
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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 |
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Objective Data |
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PE |
B/P 138/90; temperature 99°F; (RR) 20; (HR) 110, regular; oxygen saturation (PO2) 96%; pain 5/10 |
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General |
acute distress and severe pain |
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HEENT |
Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition. Piercing in her right nostril and lower lip. |
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Neck |
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Lungs |
CTA AP&L |
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Card |
S1S2 without rub or gallop |
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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 |
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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 |
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Ext |
no cyanosis, clubbing or edema |
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Integument |
intact without lesions masses or rashes |
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Neuro |
No obvious deficits and CN grossly intact II-XII |
Based on case #2 , 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 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. Your initial post is worth 8 points.
