Get Answer: Case Chief Complaint Question Guide
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Original Question
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 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. 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 Once you received your case number, answer the following questions: What other subjective data would we obtain? What other objective findings would we look for? What diagnostic exams do we want to order? Name 3 differential diagnoses based on this patient presenting symptoms? Give rationales for each differential diagnosis.
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