week 4 discussion

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

 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

• 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