NUR504- MODULE 7

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You will take on the role of a clinician who is building a health history:

CASE #2

Chief Complaint: “I have pain during intercourse and urination”

History of Present Illness (HPI): A 19-year-old female reports to you that she has “sores” on and in her vagina for the last three months.

Drug Hx: She tries to practice safe sex but has a steady boyfriend and figures she doesn’t need to be so careful since she is on the birth control pill

Subjective: states “I have sores and bumps on the inner creases of my thighs and pelvic area”. “There is yellowish discharge from the sores that comes and goes”

Objective Data: VS temperature: 100.2°F; pulse 92; respirations 18; BP 122/78; weight 156 lbs, 25 lbs overweight; height 5′3″

 General: patient appears to have good hygiene; minimal makeup, pierced ears, no tattoos; well nourished (slightly overweight); no obvious distress noted

HEENT: Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition. Piercing in her right nostril and lower lip.

Lungs: within normal limits, appropriate lung sounds auscultated, clear and equal bilaterally

Card: S1S2 without rub or gallop

Breast: • INSPECTION: no dimpling or abnormalities noted upon inspection
• PALPATION: Left breast no abnormalities noted. Right breast: denies tenderness, pain, no abnormalities noted.

Lymph: Inguinal Lymph nodes: tenderness bilaterally, numerous, 1 cm in size

Abd: tender during palpation; the left lower quadrant was very tender during palpation; patient denies nausea or vomiting

GU: labia major and minor: numerous ulcerations, too many to count; some ulcerations enter the vaginal introitus; no ulcerations in the vagina mucosa; cervix is clear, some greenish discharge; bimanual exam reveals tenderness in left lower quadrant; able to palpate the left ovary; unable to palpate the right ovary; no tenderness; uterus is normal in size, slight tenderness with cervical mobility

MS: Muscles are smooth, firm, symmetrical. Full ROM. No pain or tenderness on palpation.

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.
  6. What teachings will you provide?

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