St Thomas University Function of the C Reactive Protein Discussion Paper
Description
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
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 each differential diagnosis.
At least 500 words, formatted and cited in current 7th edition APA style with support from at least 2 academic sources.
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