Case Scenario:
"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
Birth control
NKA allergies
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.
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
- 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 No obvious deficits and CN grossly intact II-XII
500 words, formatted and cited in the current APA style with support from at least 2 academic sources