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:

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.

–Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.