Chief Complaint
(CC)
I have pain during intercourse and urination
History of Present Illness (HPI)
A 19-year-old female reports to you that she has sores on and in her vagina for the last three months.
Drug Hx
She tries to practice safe sex but has a steady boyfriend and figures she doesnt need to be so careful since she is on the birth control pill
Family Hx
Subjective
states I have sores and bumps on the inner creases of my thighs and pelvic area. There is yellowish discharge from the sores that comes and goes
Objective Data
VS
temperature: 100.2F; pulse 92; respirations 18; BP 122/78; weight 156 lbs, 25 lbs overweight; height 53
General patient appears to have good hygiene; minimal makeup, pierced ears, no tattoos; well nourished (slightly overweight); no obvious distress noted
HEENT
Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition. Piercing in her right nostril and lower lip.
Lungs
within normal limits, appropriate lung sounds auscultated, clear and equal bilaterally
Card
S1S2 without rub or gallop
Breast
INSPECTION: no dimpling or abnormalities noted upon inspection
PALPATION: Left breast no abnormalities noted. Right breast: denies tenderness, pain, no abnormalities noted.
Lymph
Inguinal Lymph nodes: tenderness bilaterally, numerous, 1 cm in size .
Abd
tender during palpation; the left lower quadrant was very tender during palpation; patient denies nausea or vomiting
GU
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
Integument
MS
Muscles are smooth, firm, symmetrical. Full ROM. No pain or tenderness on palpation.
Neuro
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?