Ms. Bell is a 28-year-old female who presents with
lower abdominal pain for two weeks: achy pelvic pain worsened by activity and
sexual intercourse. She reports associated nausea, vomiting, and alternating
loose stools and constipation. Her last menstrual period was four weeks ago;
she is sexually active without birth control and has many psychosocial
stressors and reports her husband drinks alcohol and frequently and sometimes
use physical violence. Physical examination is notable for lower abdominal
tenderness, numerous ecchymoses across her abdomen and extremities, a small
amount of yellowish, malodorous vaginal discharge, and no cervical motion
tenderness.
The ideal summary statement concisely highlights the most
pertinent features without omitting any significant points. The summary
statement above includes:
Epidemiology and risk factors: 28-year-old female, LMP
four weeks ago, sexually active without birth control
Key clinical findings about the present illness using
qualifying adjectives and transformative language:
Achy lower abdominal and pelvic pain worsened by
activity and sexual intercourse
Alternating loose stools and constipation
Many psychosocial stressors
Reports her husband drinks alcohol frequently but she
rarely drinks
Lower abdominal tenderness
Numerous ecchymoses across her abdomen and extremities
Absence of cervical motion tenderness
Small amount of yellowish, malodorous vaginal
discharge
Answer the following questions using the latest evidenced based
guidelines:
1• Discuss the questions that would be important to include when
interviewing a patient with this issue.
2• Describe the clinical findings that may be present in a patient with this
issue.
3• Are there any diagnostic studies that should be ordered on this patient?
Why?
4• List the primary diagnosis and three differential diagnoses for this
patient. Explain your reasoning for each.
4• Discuss your management plan for this patient, including pharmacologic
therapies, tests, patient education, referrals, and follow-ups.