St Thomas University Nursing Pain During Intercourse and Urination Essay
Description
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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 HxShe tries to practice safe sex but has a steady boyfriend and figures she doesn’t need to be so careful since she is on the birth control pillFamily 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 goesObjective Data VStemperature: 100.2°F; pulse 92; respirations 18; BP 122/78; weight 156 lbs, 25 lbs overweight; height 5?3? Generalpatient appears to have good hygiene; minimal makeup, pierced ears, no tattoos; well nourished (slightly overweight); no obvious distress noted
HEENTAtraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition. Piercing in her right nostril and lower lip.
Lungswithin normal limits, appropriate lung sounds auscultated, clear and equal bilaterally
CardS1S2 without rub or gallopBreast
- INSPECTION: no dimpling or abnormalities noted upon inspection
• PALPATION: Left breast no abnormalities noted. Right breast: denies tenderness, pain, no abnormalities noted.
LymphInguinal Lymph nodes: tenderness bilaterally, numerous, 1 cm in sizeAbdtender during palpation; the left lower quadrant was very tender during palpation; patient denies nausea or vomitingGUlabia 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 mobilityIntegument
MSMuscles are smooth, firm, and symmetrical. Full ROM. No pain or tenderness on palpation.NeuroNo obvious deficits and CN grossly intact II-XII
- 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’s presenting symptoms.
- Give rationales for each differential diagnosis.
- What teachings will you provide?
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