[Solved] NUR 504 Module 6

Assignment Prompt & Instructions

– ## NUR504Module6Discussion.docx

**## NUR504Module6Discussion.docx**

### Module 6 Discussion

**_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 2** |
| **Chief Complaint** | “I have pain during intercourse and urination” |
| **History of Present Illness** | 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” |
| **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 <br>• 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:**

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.**

6.
**What teachings will you provide?**

Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources within the last 5 years. Your initial post is worth 8 points.

**## NUR504Module6Discussion.docx**

### Module 6 Discussion

**_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 2** |
| **Chief Complaint** | “I have pain during intercourse and urination” |
| **History of Present Illness** | 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” |
| **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 <br>• 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:**

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.**

6.
**What teachings will you provide?**

Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources within the last 5 years. Your initial post is worth 8 points.