Learning Goal: I’m working on a nursing case study and need an explanation and a
Learning Goal: I'm working on a nursing case study and need an explanation and answer to help me learn. Case 2 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 doesn’t 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: 100.2°F; pulse 92; respirations 18; BP 122/78; weight 156 lbs, 25 lbs overweight; height 5′3″ 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? Submission Instructions: Your initial post should be at least 500 words, formatted, and cited in current APA style with support from at least 2 academic sources.

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