[Solved] week 4 discussion

Assignment Prompt & Instructions

– ## WEEK4DISCUSSION-ADVANCEHEALTHASSESSMENT.docx

**## WEEK4DISCUSSION-ADVANCEHEALTHASSESSMENT.docx**

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**<br>**(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 |
| **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<br>• AUSCULTATION: bowel sounds (BS) are normal in all four quadrants, no bruits noted<br>• 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<br>• PERCUSSION: tympany heard in all quadrants, no dullness noted in abdominal area |
| **GU** | • EXTERNAL: mature hair distribution; no external lesions on labia<br>• INTROITUS: slight green-gray discharge, no lesions<br>• VAGINAL: normal rugae; moderate amount of green discharge on vaginal walls<br>• CERVIX: nulliparous os with small amount of purulent discharge from os with positive cervical motion tenderness (CMT)<br>• UTERUS: ante-flexed, normal size, shape, and position<br>• ADNEXA: bilateral tenderness with fullness; both ovaries without masses<br>• RECTAL: deferred<br>• 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:**

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.**

**Submission Instructions:**

· Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.

**## WEEK4DISCUSSION-ADVANCEHEALTHASSESSMENT.docx**

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**<br>**(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 |
| **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<br>• AUSCULTATION: bowel sounds (BS) are normal in all four quadrants, no bruits noted<br>• 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<br>• PERCUSSION: tympany heard in all quadrants, no dullness noted in abdominal area |
| **GU** | • EXTERNAL: mature hair distribution; no external lesions on labia<br>• INTROITUS: slight green-gray discharge, no lesions<br>• VAGINAL: normal rugae; moderate amount of green discharge on vaginal walls<br>• CERVIX: nulliparous os with small amount of purulent discharge from os with positive cervical motion tenderness (CMT)<br>• UTERUS: ante-flexed, normal size, shape, and position<br>• ADNEXA: bilateral tenderness with fullness; both ovaries without masses<br>• RECTAL: deferred<br>• 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:**

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.**

**Submission Instructions:**

· Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.