Description

Female Genitourinary, & Musculoskeletal 
For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases. Your instructor will assign you your case number. CASE NUMBER 1

Case 1Case 2Case 3Chief Complaint
(CC) “I have a tumor on my left breast”“I have pain during intercourse and urination”“My back hurts so bad I can barely walk”History of Present Illness (HPI)A 55-year-old African American social worker presents to your clinic with a finding of a lump in her left breast while in the shower this past week.A 19-year-old female reports to you that she has “sores” on and in her vagina for the last three months.A 35-year-old male painter presents to your clinic with the complaint of low back pain. He recalls lifting a 5-gallon paint can and felt an immediate pull in the lower right side of his back. This happened 2 days ago and he had the weekend to rest, but after taking Motrin and using heat, he has not seen any improvement. His pain is sharp, stabbing, and he scored it as a 9 on a scale of 0 to 10.Drug HxI took birth control pills for 10 years, starting when I was 20 I am not on hormone replacementShe 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 Motrin for pain.Family HxMy grandmother had breast cancer when she was 76 years old Father hypertension
Mother DM
Subjective
Denies any fever or chills. No changes in vision or hearing, no difficulty chewing or swallowing. Supple neck, states that she does self-breast-exams on occasion. Menopause at 52
No skin changes or nipple discharge from the left breast
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”He is having some right leg pain but no bowel or bladder changes. No numbness or tinglingObjective Data VStemperature 98.6°F; respiratory rate (RR) 16; heart rate (HR) 80, regular; blood pressure (BP) 130/84; height: 5?8?; weight 160 lbs; body mass index (BMI) 24temperature: 100.2°F; pulse 92; respirations 18; BP 122/78; weight 156 lbs, 25 lbs overweight; height 5?3?temperature: 98.2°F, respiratory rate 16, heart rate 90, blood pressure 120/60
O2 saturation 98%
Generalwell developed, nourished, healthy-appearing femalepatient appears to have good hygiene; minimal makeup, pierced ears, no tattoos; well nourished (slightly overweight); no obvious distress notedwell-developed healthy 35-year-old male; no gross deformities HEENTAtraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear, nares patent, nasopharynx clear, edentulous.
Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition. Piercing in her right nostril and lower lip.
Atraumatic, normocephalic, PERRLA, EOMI, sclera with mild icterus, nares patent, nasopharynx clear, poor dentition – multiple carries.Lungsclear to auscultation
within normal limits, appropriate lung sounds auscultated, clear and equal bilaterally
CTA AP&LCardregular rate and rhythm (RRR)S1S2 without rub or gallopS1S2 without rub or gallopBreastExamined in sitting and supine positions. In sitting position, no evidence of skin changes, right breast is slightly larger than the left, symmetrical movement with the arms above the head and at the side and with flexion of the pectoral muscles; 5-mm nonmobile, non-tender, firm mass felt at 10 o’clock position, 5 cm from the areola. Right breast without dominant masses or tenderness. Nipples without inversion or evidence of nipple discharge. Breast mass is palpated in the supine position in the same manner as in the sitting position
INSPECTION: no dimpling or abnormalities noted upon inspection
• PALPATION: Left breast no abnormalities noted. Right breast: denies tenderness, pain, no abnormalities noted.
INSPECTION: no dimpling or abnormalities noted upon inspection
PALPATION: Left breast – no abnormalities noted. Right breast – denies tenderness, pain, no abnormalities noted.
Lymphnegative axillary, infraclavicular, and supraclavicular lymphadenopathyInguinal Lymph nodes: tenderness bilaterally, numerous, 1 cm in sizeno bruising, fever, or swelling noted, no acute bleeding or trauma to skin.Abdnormoactive bowel sounds x 4;tender during palpation; the left lower quadrant was very tender during palpation; patient denies nausea or vomitingbenign, normoactive bowel sounds x 4; Hepatomegaly 2cm below the costal margin.GUBladder is non-distended.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 mobilityBladder is non-distended.Integumentgood skin turgor noted, moist mucous membranesintact without lesions masses or rashes.MSMuscles are smooth, firm, symmetrical. Full ROM. No pain or tenderness on palpation.Muscles are smooth, firm, symmetrical. Full ROM. No pain or tenderness on palpation.No obvious deformities, masses, or discoloration. Palpable pain noted at the right lower lumbar region. No palpable spasms. ROM limited to forward bending 10 inches from floor; able to bend side to side but had difficulty twisting and going into extension. NeuroNo obvious deformities, CN grossly intact II-XIINo obvious deficits and CN grossly intact II-XIIDTRs 2+ lower sensory neurology intact to light touch and patient able to toe and heel walk. Gait was stable and no limping noted.
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?
 Hi, Here are attached the 2 discussions that need replies. I need the peer responses in 14 hrs.peer1 case 2 Alena:Additional Subjective Data            The additional subjective data for the 19-year-old female with pain during urination and intercourse include probing for the onset of the pain, whether abrupt or gradual, radiating and relieving factors, and alleviating and aggravating factors such as what worsens the pain or reduces pain, including any medications. Further additional subjective data include the severity of pain on a scale of one to ten, with ten being the most severe, history of sexually transmitted infections, the characteristics of the vaginal discharge such as odor, patterns on her menstrual cycle, allergies, bloody urine, and use of contraceptives. Do the sores cause itching or burning, and if there is pain during bowel movement, diarrhea, and bloody or mucus stool.Additional Objective Data            The additional objective data on the patient focuses on revealing the cause of the signs and symptoms presented by the patient (Petersen & Rhoads, 2021). Such objective data include a physical examination of the vaginal and thigh sores, palpation of the abdomen, and determining if the patient has any abdominal pain or tenderness. Other objective information includes cervical friability, photophobia, testing urine samples for blood and infections, and testing vaginal discharge will give more objective data on the patient.Diagnostic ExamsThe recommended diagnostic tests for the patient include microscopy culture and sensitivity tests. The microscopy culture determines what is responsible for the infection, while the sensitivity test informs the type of medication for the confirmed infection (Vargas et al., 2021; Vitale & Lockwood, 2020). Another recommended test is a urinalysis test or a vaginal swab which helps detect chlamydia trachomatis, HSV-2 or other sexually transmitted infections. A complete blood test is also recommended for the patient to detect if white blood cells are elevated to confirm possible infection (Nouraddin & Alsakee, 2019). A pregnancy test and HIV test are also recommended for the patient.  Differential Diagnoses            The differential diagnoses for the patient include HSV-2, chlamydia trachomatis and gonorrhea or urinary tract infection (UTI). HSV-2 presents with pain and itching around genitals, small bumps and blisters that rupture and ooze, vaginal discharge and pain during urination. Chlamydia trachomatis presents signs and symptoms similar to those presented by the patient, such as fever, abnormal vagina discharge, pain urinating during intercourse, and abdominal tenderness (Henigsman, 2021). Gonorrhea presents with fever, cervical motion tenderness, discolored vaginal discharge, painful urination and intercourse, and lower abdominal discomforts (Centers for Disease Control and Prevention, 2022). Further, gonorrhea is a sexually transmitted infection among young people aged 15 to 24 (CDC, 2022). Urinary tract infection presents with signs and symptoms such as pain passing urine, fever, and vaginal discharge, which the patients present with (Chu & Lowder, 2018). Further, UTI causes pain in the lower abdomen and pain during intercourse.Patient Teachings            The patient’s teachings include abstaining or use of protection during sexual intercourse to prevent reoccurrences of sexually transmitted infections. The other education is on the need to have her sexual partner(s) tested and treated to prevent reinfection. The patient needs to be educated on importance of good hygiene. The patient needs to be taught how to use the prescribed medications, such as dosage, possible side effects, and frequency, and adhere to follow-up and monitoring schedules. Lastly, the patient is overweight, and teachings on the need and ways of maintaining a healthy weight are essential, as well as the need for contraceptives (if not planning to get a child) to avoid unplanned pregnancies.ReferencesCenters for Disease Control and Prevention. (2022). Gonorrhea – CDC Fact Sheet https://www.cdc.gov/std/gonorrhea/stdfact-gonorrhea.htmLinks to an external site.Chu, C. M., & Lowder, J. L. (2018). Diagnosis and treatment of urinary tract infections across age groups. American Journal of Obstetrics and Gynecology, 219(1), 40-51. https://doi.org/10.1007/978-3-030-29138-9_8Henigsman, S. (2021). Chlamydia May Not Have Symptoms, But It Can Still Cause Health Issues. Healthline. https://www.healthline.com/health/std/chlamydia.Nouraddin, A., & Alsakee, H. (2019). Immunological Aspects of Trichomonas vaginalis Infection in Women Attending Maternity Teaching Hospital and Some Public Health Centers in Erbil Governorate, Northern Iraq. Cihan University-Erbil Scientific Journal, 3(1), 56-60. https://doi.org/10.24086/cuesj.v3n1y2019.pp56-60Links to an external site.Petersen, S. W. & Rhoads, J. (2021). Advanced health assessment and diagnostic reasoning. Jones & Bartlett Learning. 4th EditionVargas, S., Calvo, G., Qquellon, J., Vasquez, F., Blondeel, K., Ballard, R., & Toskin, I. (2021). Point-of-care testing for sexually transmitted infections in low-resource settings. Clinical Microbiology and Infection. https://doi.org/10.1016/j.cmi.2021.05.052Links to an external site.Vitale, A. M., & Lockwood, G. M. (2020). Urine Microscopy: The Burning Truth–White Blood Cells in the Urine. Urine Tests: A Case-Based Guide to Clinical Evaluation and Application, 143-166. https://doi.org/10.1007/978-3-030-29138-9_8peer 2 Barbaro YohendryCase Study # 3Subjective data       Subjective data in nursing comprises details relating to personal feelings and cannot be observed – the nurse cannot experience them. In case study 3, the most critical subjective findings include history records, such as the father’s hypertension and the mother’s diabetes mellitus (DM). In addition, information about the patient’s present drug, like Motrin for pain, is essential in determining what drugs to use. The patient’s feelings are derived from their verbal statements, critical information for his diagnosis (Toney-Butler & Thayer, 2022). The patient’s statement on having right leg pain without bowel, no bladder changes, no tingling, or no numbness is vital to the correct diagnosis.Objective findings      Objective findings in nursing involve information that the nurse or someone else can measure, observe, or experience. This is factual, tangible, repeatable, and quantifiable (Toney-Butler & Thayer, 2022). Therefore, I would look for the vital signs, such as height, weight, blood pressure, body temperature, respiratory rate of 16, heart rate, and O2 saturation. Other general characteristics include no gross deformities and a healthy body. The nurse could also measure lung, cardiovascular, abdominal, neurology, breast, and lymph functioning.Diagnostic exams      An efficient diagnostic examination would allow experimental treatment of the patients. The nurse or attending healthcare professional will examine the patient’s back and assess their capacity to sit, walk, stand, and lift their legs. Rating the pain on a 0-10 scale and talking more about how the pain impacts the patient’s daily activities is crucial to enhancing precise diagnosis. This will be crucial for identifying the source and the duration of pain and if the patient encounters muscle spasms. Tests to rule out potentially severe causes of back pain include X-rays, blood tests, MRI or CT scans, and nerve studies, as Pangarkar et a. (2019) guide.      An X-ray can show the potential problem with muscles, spinal cord, and disks or nerves. An MRI or CT scan provides images revealing herniated problems or disks with muscles, bones, tendons, tissues, blood vessels, ligaments, and nerves. Electromyography (EMG) could also help study the nerves and the back muscle’s responses to electrical pulses. Besides, blood tests may determine an infection or another potential disorder causing pain. The test can validate pressure on the nerves.  Three differential diagnoses and rationale for each       Lumbar muscular strain is one of the differential diagnoses for the patient’s severe pain in the lower back. The health condition results from impaired tendons and muscles within the lower back. The patient’s lifting of the 5-gallon paint can cause lumbar strain on the right side. Every individual may encounter symptoms differently, mainly sudden lower back pain, soreness in the lower back, and spasms within the lower back due to severe pain. The stabbing and sharp pain may be an illustration of another health condition. The rationale for lumbar muscle strain is that it occurs when a muscle fiber is strangely stretched or torn due to abrupt injury or gradual abuse.      Herniated nucleus pulposus is a second differential diagnosis for the patient’s back pain. The condition results due to prolapse of an intervertebral disk via a tear within the annulus fibrosus (Kim et al., 2022). The slit causes increased pain due to the irritating sensory nerves within the disk, distributing the effects on nerve roots. A CT or MRI typically confirms its diagnosis. The rationale for herniated nucleus pulposus is pain, numbness, tingling, and muscle feebleness because of spinal cord compression or nerve root.       Spinal stenosis occurs due to spinal canal narrowing, mainly within the lower part of the back. This creates excessive pressure on the spinal nerves or cord that causes severe pain in the lower back or lumbar area (Katz et al., 2022). Its symptoms depend on the affected spinal cord area. In the lower back, spinal stenosis cause cramping and pain in the two legs, especially when one stands or walks for a long. Symptoms appear after bending or sitting, with most people experiencing back pain. The rationale for this condition includes pain, body weakness, and numbness, with severe pain causing bowel and bladder control loss.The teaching provided       Patient education on healthy lifestyles would enhance self-management and relieve the symptoms, as O’Hagan et al. (2022) argue. The patient should also be trained to use the prescribed pain-relieving medication better. Guidance on healthy exercises and diets is also essential to attain good health, which permits healthy walking and relieves associated symptoms.ReferencesKatz, J. N., Zimmerman, Z. E., Mass, H., & Makhni, M. C. (2022). Diagnosis and management of lumbar spinal stenosis: a review. Jama, 327(17), 1688-1699. https://doi:10.1001/jama.2022.5921Kim, J. H., Lee, S. E., Jung, H. S., Shim, B. S., Hou, J. U., & Kwon, Y. S. (2022). Development and Validation of Deep Learning-Based Algorithms for Predicting Lumbar Herniated Nucleus Pulposus Using Lumbar X-rays. Journal of Personalized Medicine, 12(5), 767. https://doi.org/10.3390/jpm12050767Links to an external site.O’Hagan, E. T., Di Pietro, F., Traeger, A. C., Cashin, A. G., Hodges, P. W., Wand, B. M., … & McAuley, J. H. (2022). What messages predict the intention to self-manage low back pain? A study of attitudes towards patient education. Pain, 163(8), 1489-1496.Pangarkar, S. S., Kang, D. G., Sandbrink, F., Bevevino, A., Tillisch, K., Konitzer, L., & Sall, J. (2019). VA/DoD clinical practice guideline: diagnosis and treatment of low back pain. Journal of general internal medicine, 34, 2620-2629. https://doi.org/10.1007/s11606-019-05086-4Links to an external site.  Toney-Butler, T. J., & Thayer, J. M. (2022). Nursing process. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499937/Links to an external site.

  
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