Role of a clinician

Role of a clinician

For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases. Your instructor will assign you your case number.

“I have pain in my belly”

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

Patient denies

Birth control

NKA

Nausea and vomiting, Last menstrual period 5 days ago, New sexual partner about 2 months ago, No condoms, he hates them No pain, blood or difficulty with urination

B/P 138/90; temperature 99°F; (RR) 20; (HR) 110, regular; oxygen saturation (PO2) 96%; pain 5/10

acute distress and severe pain

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

CTA AP&L

S1S2 without rub or gallop

• INSPECTION: no masses or thrills noted; no discoloration and skin is warm to; no tattoos or piercings; abdomen is nondistended and round
• AUSCULTATION: bowel sounds (BS) are normal in all four quadrants, no bruits noted
  • 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
  • PERCUSSION: tympany heard in all quadrants, no dullness noted in abdominal area
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• • EXTERNAL: mature hair distribution; no external lesions on labia
  • INTROITUS: slight green-gray discharge, no lesions
  • VAGINAL: normal rugae; moderate amount of green discharge on vaginal walls
  • CERVIX: nulliparous os with small amount of purulent discharge from os with positive cervical motion tenderness (CMT)
  • UTERUS: ante-flexed, normal size, shape, and position
  • ADNEXA: bilateral tenderness with fullness; both ovaries without masses
  • RECTAL: deferred
  • VAGINAL DISCHARGE: green in color
• no cyanosis, clubbing or edema
• intact without lesions masses or rashes
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• No obvious deficits and CN grossly intact II-XIIOnce 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.
  6. Your instructor will assign you your case number and you will post on the case number you have been assigned.
  7. You will reply to the other two case studies (One of each).
  8. Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources. Your initial post is worth 8 points.
  9. You should respond to at least two of your peers by extending, refuting/correcting, or adding additional nuance to their posts. Your reply posts are worth 2 points (1 point per response.)
  10. All replies must be constructive and use literature where possible.
  11. Please post your initial response by 11:59 PM ET Thursday, and comment on the posts of two classmates by 11:59 PM ET Sunday.
  12. You can expect feedback from the instructor within 48 to 72 hours from the Sunday due date.
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Requirements: More 600 words

Answer preview to role of a clinician

APA

750 WORDS

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