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Case Presentation: A 25-year-old female presents to the emergency department (ED)
with complaints of severe abdominal pain.
Physical Examination Findings
VITALSIGNS:temperature99°F;respiratoryrate(RR)20;heartrate(HR)110,regular;
BP 138/90; oxygen saturation (SpO2) 96%; pain 5/10
GENERAL APPEARANCE: female in acute distress and severe pain
HEAD, EYES, EARS, NOSE, THROAT (HEENT): within normal limits; eyes: anicteric;
pupils equal, round, and reactive to light and accommodation (PERRLA); nose: no
discharge; mouth/throat: moist membranes, no lesions
CHEST: lung clear in all fields; S1S2, no murmurs, gallops, or rubs
ABDOMEN:soft,diffusetenderness
SKIN:norashes
EXTREMITIES:rangeofmotion(ROM)×4,nojointpainorswelling
Abdominal Examination
INSPECTION:nomassesorthrillsnoted;nodiscolorationandskiniswarmtothe
touch; no tattoos or piercings; abdomen is nondistended and round
AUSCULTATION:BSarenormalinallfourquadrants,nobruitsnoted
PALPATION:onpalpation,abdomenistendertotouchinfourquadrants;tenderness
noted on light palpation, deep palpation reveals no masses, spleen and liver unremark-
able
PERCUSSION:tympanyheardinallquadrants,nodullnessnotedinabdominalarea
Pelvic Examination
EXTERNAL:maturehairdistribution;noexternallesionsonlabia
INTROITUS:slightgreen-graydischarge,nolesions
VAGINAL:normalrugae;moderateamountofgreendischargeonvaginalwalls
CERVIX:nulliparousoswithsmallamountofpurulentdischargefromoswithpositive
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
Please use the information provided above along the the information in the document label Case 2 , and text book ( section abdominal pain page 23 to 29) . To complete the case analysis template attached.
this is the original info given by the professor
If you have not yet completed or submitted Case Analysis 2…. Consider using this format.
Case-Study information [patient, age, etc]
Subjective
Objective
Diagnostic Findings (if provided)
Assessment : :List/Provide 4 diagnoses with at least one being health promotion/education.
Diagnose 1: (What evidence supports this dx)
Diagnose 2 – include ICD10: (What evidence supports this dx)
Diagnose 3: Include ICD10:(What evidence supports this dx)
Diagnose 4: Include ICD10:(What evidence supports this dx)
Plan – (orders to manage each dx, *with rationale – evidence-based reference)
Diagnose 1
* Treatment Plan/Order
Diagnose 2
* Treatment Plan/Order
Diagnose 3
* Treatment Plan/Order
Diagnose 4
* Treatment Plan/Order
Reference Page
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