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For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases.

Case 2

Chief Complaint

(CC)

“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

Family Hx

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

Integument

MS

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

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 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 your each differential diagnosis.

What teachings will you provide?

  
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