Case #2 Differential DiagnosesCase study & Differential DiagnosisAge 20 yoGender Female

Question Answered step-by-step Case #2 Differential DiagnosesCase study & Differential DiagnosisAge 20 yoGender FemaleInformant Ms. SPreferred pronouns: her, sheReliability: appears reliable CC : 20- yo female c/o abdominal pain and vaginal bleeding x 3 daysHPI: 20-year-old healthy female c/o right sided abdominal pain with severe cramping with menses that started 2 days ago and is getting worse, pt states for past 4-months has had history of severe painful menstrual cramps accompanied by painful intercourse. Severe menstrual cramping and pain began 4 months ago when OCPs were changed; the pain was so severe that she reported several instances of absence from work, takes naproxen 550 mg daily when cramps and pain begin with no relief. Painful cramping started 3 days before menses this time, with the worst pain is today rated at 10/10.PMHxHuman papillomavirus (HPV) at age 19DysmenorrheaPSHx- deniesGYN: P1G1010, Menses started age 14, + sexually active, denies use condoms, + take OCPs, 4 lifetime partners, + HPV, denies other STIs, never tested for HIVMedications:Low-dose OC: 30 ethinyl estradiol/0.15 desogestrel po daily.Naproxen 550 mg BID prn menstrual pain. All:​NKMA Health Maintenance​Immz: UTD, + yearly flu vaccine​Pap: Abnormal Papanicolau (Pap) smear 1 year agoSocial HxLives alone in 1 bedroom 2 story walk up apt. Boyfriend visits often, family lives in Florida- but communicates with them often, is close to her 2 sisters who are older than her, enjoys her life, denies significant stressorsHabits:Tobacco: smoked ‘socially’ as teenageAlcohol: beer and wine about 2 times per weekIllicit drugs: + occasional marijuana use, denies any other drugsExercise: Does not exercise regularly​​Sleep: 6-7 hours a nightNutrition tries to eat healthy, but does not follow specific dietOccupational history: works as assistant in fashion company.Abuse history: denies emotional, physical or sexual abuse, feels safe with partnersSexual history: 4 lifetime partners, gender- all male, sexual orientation- heterosexual, HIV status- never been tested, use of STI protection= does not use, Pregnancy prevention – OCPsREVIEW OF SYSTEMS General:Denies any fevers, c/o weight gain of about 10 lbs over past 6 months Skin:Denies any rashes, c/o increased hair growth to chin and skin darkening around neck HEENT:Head: denies any headaches, no hair loss Eyes: denies redness, d/c or itching, denies blurry vision Ears: denies ear pain, hearing difficulties. Nose & sinuses: denies nasal d/c, sinus pressure Oropharynx: denies sore throat, difficulty swallowing, pain, change in taste, malodorous breath, or bleeding Neck:Denies stiffness or swelling, + darkening of skin around neck Breast:Denies masses, pain, nipple discharge, does not perform self breast exam Respiratory:Denies cough, hemoptysis, asthma, chest tightness, sputum, or shortness of breath Cardiovascular:Denies chest pain, palpitations or syncope GI:c/o abdominal pain/cramping started with menses and is getting worse, c/o pain to right side for past 2 days, + nausea but denies vomiting or diarrhea, denies appetite change but states gained 10 lbs over 6 months, denies indigestion, belching, bloating, heartburn, or change of bowel function, tries to ‘eat healthy’ diet? Last BM today GU:any urinary frequency, urgency, dysuria, Female:/GYN  menstrual history:  menarche: age 14 years, + history ofdysmenorrhea, denies vag d/c or lesions, + sexually active with male partner- vaginal and oral sex  Musculoskeletal:Denies any joint pains, stiffness, or swelling Neurologic:Denies syncope, seizures, ataxia, dizziness, weakness or headaches Psychiatric:denies depression, suicidal ideation or anxiety, hallucinations, sleep disorders, or change in libido  Hematologic:Denies any easy bruising, bleeding, past transfusions, IV drug use history, Endocrine:Denies heat/cold intolerance, + skin changes to neck, denies polydipsia, polyphagia, polyuria, striae, thyroid or other known endocrine disorders?  Physical Exam Vitals Ht: 157.2 cmWt:  86 kgTemp: 98.2HR: 85RR 16B/P 130/80 General:​A & O x 3, well appearing 20 yo female in NADSkin:​+ acanthosis to posterior neck, no other rashes, lesions or scars notedHEENT:​Head: NCAT, no hair loss or infestationsEyes: symmetrical, conjunctiva pale, sclera clear, PERRLA, optic disc magins sharp no papilledema noted.Ears: symmetrical, canals patent, TMs pearl, + LM, + LRNose: nares patents, no d/c, no sinus tendernessMouth/throat: MMM, tonsils +1, no lesions noted, uvula midline, teeth intactNeck​Supple, full ROM ,no thyromegaly or lymphadenopathy, + acanthosis noted posteriorlyChest/Lungs​RR 16, no retractions or accessory muscle use, lungs CTACV: ​HRR 85 bpm, S1, S2 intact no murmurs, rubs or gallops, no thrills, no heaves or lifts noted, capillary refill < 3 seconds, no peripheral edema Abdomen:Soft, non distended, obese, + BS x 4 quadrants, no bruits, no HSM, + right lower quadrant tenderness with palpation, no rebound, no masses, no CVA tenderness Genital/GYNTanner V, urethra midline, no lesions noted, labia without swelling or lesions, + blood in vaginal vault with scattered clots; + right adenexal tenderness on palpation, no masses, no adenexal tenderness to left,  no CMT, os closed.Rectal:​No lesions, + anal wink, stool guiac negativeMS:​Moves all extremities, no swelling, tenderness or limitation of motionNeuro:​A & O x 3, no weakness noted, moving all extremities.  Assessment:  (60%) • Identify at least 4 differential diagnoses for this patient based on the history and exam findings. (20%)• List the ICD 10 codes for each differential diagnosis  (5%)• Identify: positives and negatives for each differential: Include the positive history and physical exam findings that support each differential & the negative- things that do not support EACH differential  (15%)• List all labs and tests you would complete on this patient with a rationale for each lab/test you are ordering (15%)• Identify what you ths is the most likely FINAL diagnosis for this patient based on the history and exam with ICD 10 -code (5%) Plan of Care (40%)• For each differential diagnosis provide a plan of care that you would implement include:o Medications (with dosing) (10%)o additional tests, (10%)o patient education, (10%)o referrals (5%)o follow up recommendations including when to go to the ED  (5%)             Health Science Science Nursing NURS MISC Share QuestionEmailCopy link Comments (0)