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St Thomas University Function of the C Reactive Protein Discussion Paper

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

    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.
    6. 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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