for this discussion we are gonna use case #2 as well thank you for everything
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 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?
Expert Solution Preview
Introduction:
As a medical professor, it is my responsibility to design assignments and evaluate the performance of medical college students. In this case, we will be analyzing a patient’s health history to determine the next steps in their care. We will examine their chief complaint, history of present illness, drug history, family history, subjective and objective data, and formulate differential diagnoses. Based on this information, we will also discuss the diagnostic exams to order and the teachings to provide to the patient.
Answer to Question 1:
To obtain additional subjective data, I would inquire about the patient’s medical history, including any previous surgeries or chronic illnesses. I would ask about their lifestyle habits, such as smoking, alcohol consumption, and exercise routine. It would also be important to assess the patient’s sexual history, including the frequency of intercourse and any recent changes or new partners. Lastly, I would ask about their menstrual history, any abnormal bleeding, and the presence of any other symptoms that could be associated with their chief complaint.
Answer to Question 2:
To look for additional objective findings, I would perform a thorough physical examination. This would include a comprehensive breast examination to assess any other masses, skin changes, or nipple discharge. In the case of the patient with pain during intercourse and urination, a pelvic examination would be necessary to assess for any abnormal findings or lesions. For the patient with back pain, a musculoskeletal examination would be conducted to assess for any deformities, muscle spasms, or limitations in range of motion.
Answer to Question 3:
Based on the presenting symptoms and findings, I would order the following diagnostic exams:
1. Mammogram and/or ultrasound for the patient with a breast lump to further evaluate the nature of the mass and determine if it is benign or suspicious for malignancy.
2. A comprehensive sexually transmitted infection (STI) testing panel for the patient with genital sores and bumps, including tests for herpes simplex virus, syphilis, gonorrhea, and chlamydia.
3. Imaging studies such as X-ray, MRI, or CT scan for the patient with back pain to assess for possible musculoskeletal or spinal abnormalities.
Answer to Question 4:
Three potential differential diagnoses based on the patient’s presenting symptoms are as follows:
1. Breast cancer for the patient with a breast lump.
2. Genital herpes for the patient with genital sores and discharge.
3. Lumbar disc herniation or musculoskeletal strain for the patient with back pain.
Answer to Question 5:
Rationales for each differential diagnosis are as follows:
1. Breast cancer is a potential differential diagnosis due to the patient’s age, finding of a lump, and family history of breast cancer.
2. Genital herpes is a consideration given the patient’s symptoms of sores and discharge, which are characteristic of this sexually transmitted infection.
3. Lumbar disc herniation or musculoskeletal strain could be responsible for the patient’s back pain, considering the recent lifting of a heavy object and the absence of improvement with rest and conservative measures.
Answer to Question 6:
Teachings for the patient may include self-breast examination techniques, the importance of safe sex practices and regular STI screenings, and proper body mechanics and lifting techniques to prevent back injuries. Additional teachings may include information on the signs and symptoms of breast cancer, sexually transmitted infections, and strategies for managing back pain, such as stretching exercises and proper posture. It is important to provide the patient with resources and support to address their specific health concerns.
Please note that this answer is provided based on the given content and does not reflect specific individual or medical advice.
