For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases.
â€œI have pain during intercourse and urinationâ€
History of Present Illness (HPI)
A 19-year-old female reports to you that she has â€œsoresâ€ on and in her vagina for the last three months.
She tries to practice safe sex but has a steady boyfriend and figures she doesnâ€™t need to be so careful since she is on the birth control pill
states â€œI have sores and bumps on the inner creases of my thighs and pelvic areaâ€. â€œThere is yellowish discharge from the sores that comes and goesâ€
temperature: 100.2Â°F; pulse 92; respirations 18; BP 122/78; weight 156 lbs, 25 lbs overweight; height 5â€²3â€³
patient appears to have good hygiene; minimal makeup, pierced ears, no tattoos; well nourished (slightly overweight); no obvious distress noted
Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition. Piercing in her right nostril and lower lip.
within normal limits, appropriate lung sounds auscultated, clear and equal bilaterally
S1S2 without rub or gallop
INSPECTION: no dimpling or abnormalities noted upon inspection
â€¢ PALPATION: Left breast no abnormalities noted. Right breast: denies tenderness, pain, no abnormalities noted.
Inguinal Lymph nodes: tenderness bilaterally, numerous, 1 cm in size
tender during palpation; the left lower quadrant was very tender during palpation; patient denies nausea or vomiting
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
Muscles are smooth, firm, symmetrical. Full ROM. No pain or tenderness on palpation.
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?