Discussion Week 5 health assessment

I’m stuck on a Nursing question and need an explanation.

Gastrointestinal & Endocrine


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 2
Chief Complaint
(CC)
“I have pain in my belly”
History of Present Illness (HPI) 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
PMH Patient denies
PSH
Drug Hx
Birth control
Allergies NKA
Subjective 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
Objective Data
PE B/P 138/90; temperature 99°F; (RR) 20; (HR) 110, regular; oxygen saturation (PO2) 96%; pain 5/10
General acute distress and severe pain
HEENT . Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition. Piercing in her right nostril and lower lip.
Neck
Lungs CTA AP&L
Card S1S2 without rub or gallop
Abd

• 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

GU • 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
Ext no cyanosis, clubbing or edema
Integument intact without lesions masses or rashes
Neuro No obvious deficits and CN grossly intact II-XII

Once you received your case number, answer the following questions:

  1. What other subjective data would you obtain?
  2. What other objective findings would you look for?
  3. What diagnostic exams do you want to order?
  4. Name 3 differential diagnoses based on this patient presenting symptoms?
  5. Give rationales for your each differential diagnosis.

Submission Instructions:

  • Your instructor will assign you your case number and you will post on the case number you have been assigned.
  • You will reply to the other two case studies (One of each).
  • Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.

Your assignment will be graded according to the grading rubric.

Discussion Rubric
Criteria Ratings Points

Identification of Main Issues, Problems, and Concepts

5 points
Distinguished

Identify and demonstrate a sophisticated understanding of the issues, problems, and concepts.

4 points
Excellent

Identifies and demonstrates an accomplished understanding of most of the issues, problems, and concepts.

2 points
Fair

Identifies and demonstrates an acceptable understanding of most of the issues, problems, and concepts.

1 point
Poor

Identifies and demonstrates an unacceptable understanding of most issues, problems, and concepts.

5 points

Use of Citations, Writing Mechanics and APA Formatting Guidelines

3 points
Distinguished

Effectively uses the literature and other resources to inform their work. Exceptional use of citations and extended referencing. High level of APA precision and free of grammar and spelling errors.

2 points
Excellent

Effectively uses the literature and other resources to inform their work. Moderate use of citations and extended referencing. Moderate level of APA precision and free of grammar and spelling errors.

1 point
Fair

Ineffectively uses the literature and other resources to inform their work. Moderate use of citations and extended referencing. APA style and writing mechanics need more precision and attention to detail.

0 point
Poor

Ineffectively uses the literature and other resources to inform their work. Unacceptable use of citations and extended referencing. APA style and writing mechanics need serious attention.

3 points
Response to Posts of Peers

2 points
Distinguished

The student constructively responded to two other posts and either extended, expanded, or provided a rebuttal to each.

1 point
Fair

The student constructively responded to one other post and either extended, expanded, or provided a rebuttal.

0 point
Poor

The student provided no response to a peer’s post.

2 points

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