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Case #2 Differential Diagnoses Case study & Differential...

Case #2 Differential Diagnoses

Case study & Differential Diagnosis

Informant Ms. S

Age 20 yo

Gender Female

Preferred pronouns: her, she

Reliability: appears reliable

 

CC : 20- yo female c/o abdominal pain and vaginal bleeding x 3 days

HPI: 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.

PMHx

Human papillomavirus (HPV) at age 19

Dysmenorrhea

PSHx- denies

GYN: P1G1010, Menses started age 14, + sexually active, denies use condoms, + take OCPs, 4 lifetime partners, + HPV, denies other STIs, never tested for HIV

Medications:

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 ago

Social Hx

Lives 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 stressors

Habits:

Tobacco: smoked 'socially' as teenage

Alcohol: beer and wine about 2 times per week

Illicit drugs: + occasional marijuana use, denies any other drugs

Exercise: Does not exercise regularly​​

Sleep: 6-7 hours a night

Nutrition tries to eat healthy, but does not follow specific diet

Occupational history: works as assistant in fashion company.

Abuse history: denies emotional, physical or sexual abuse, feels safe with partners

Sexual history: 4 lifetime partners, gender- all male, sexual orientation- heterosexual, HIV status- never been tested, use of STI protection= does not use, Pregnancy prevention - OCPs

REVIEW 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 cm

Wt:  86 kg

Temp: 98.2

HR: 85

RR 16

B/P 130/80

 

General:

​A & O x 3, well appearing 20 yo female in NAD

Skin:

​+ acanthosis to posterior neck, no other rashes, lesions or scars noted

HEENT:

​Head: NCAT, no hair loss or infestations

Eyes: symmetrical, conjunctiva pale, sclera clear, PERRLA, optic disc magins sharp no papilledema noted.

Ears: symmetrical, canals patent, TMs pearl, + LM, + LR

Nose: nares patents, no d/c, no sinus tenderness

Mouth/throat: MMM, tonsils +1, no lesions noted, uvula midline, teeth intact

Neck

​Supple, full ROM ,no thyromegaly or lymphadenopathy, + acanthosis noted posteriorly

Chest/Lungs

​RR 16, no retractions or accessory muscle use, lungs CTA

CV: ​

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/GYN

Tanner 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 negative

MS:

​Moves all extremities, no swelling, tenderness or limitation of motion

Neuro:

​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%)

 

 

 

 

 

 

 

 

 

 

 

 

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