ASSIGNMENT HELP | Discuss what questions you would ask the patient, what physical exam elements you would include, and what further testing you would want to have performed.

Case :A 23-year old female complains of severe left lower abdominal/pelvic pain for 6 hours. States her last menstrual period was “about 3 or 4 weeks ago”. She is sexually active and denies using any contraceptive method.

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For the case you have chosen, post to the discussion:

1.Discuss what questions you would ask the patient, what physical exam elements you would include, and what further testing you would want to have performed.
2.In SOAP format, list:
3.Pertinent positive and negative information
4.Differential and working diagnosis
5.Treatment plan, including: pharmacotherapy with complementary and OTC therapy, diagnostics (labs and testing), health education and lifestyle changes, age-appropriate preventive care, and follow-up to this visit.
6.Use at least one scholarly source other than your textbook to connect your response to national guidelines and evidence-based research in support of your ideas.

MODEL ANSWER

Health/Physical Assessment

S

Severe left lower abdominal/pelvic pain for six hours

HPI

Provocation/palliation

Did the pain start on its | PLACE YOUR ORDER NOW AT writtask.com | you were doing at the time?

What eases the pain? What | PLACE YOUR ORDER NOW AT writtask.com | walking, standing?

Do you use cold/heat compresses?

Did you travel recently?

Quality/Quantity

How does the pain feel? Sharp, stabbing, dull?

Region/radiation

Where exactly is the location of the pain?

Is it radiating? If yes, in which | PLACE YOUR ORDER NOW AT writtask.com | else and not it has become localized in one part?

Severity

On a scale of 1-10 with zero being no | PLACE YOUR ORDER NOW AT writtask.com | you rate your pain? Does it affect your daily duties? How bad does the pain become?

Timing

For how long have you felt the pain? Is the | PLACE YOUR ORDER NOW AT writtask.com | it last? Do you have any other symptoms?

PH: The patient should be asked | PLACE YOUR ORDER NOW AT writtask.com | surgical procedures, medical history, and the medical history of family.

Social history: Such aspects as tobacco and | PLACE YOUR ORDER NOW AT writtask.com | about physical activity and food and nutrition.

Allergies: Ask about any kind of allergic reactions to either food or medication.

Medication: Ask questions | PLACE YOUR ORDER NOW AT writtask.com | and over-the-counter medications?

ROS:

Cardiac: Conduct an assessment of the cardiac system

Respiratory: conduct an assessment of the respiratory system

GI: Do you feel | PLACE YOUR ORDER NOW AT writtask.com | have diarrhea? Constipation?

GU: How regular are your periods? Are the periods | PLACE YOUR ORDER NOW AT writtask.com | Pap smear? What were the results? Pain during sex? Abnormal discharge?

O

ROS

General appearance: Give a general description of | PLACE YOUR ORDER NOW AT writtask.com | and any vital signs. Ask her for presence of chills or fever.

HEENT: Perform a head, eyes, ears, nose and throat assessment

Cardiac: Perform a cardiac assessment

Respiratory: Perform a respiratory assessment

A

Diagnosis

Uncomplicated ruptured ovarian cyst: In this condition | PLACE YOUR ORDER NOW AT writtask.com | and is unilateral. The pain is sharp and localized, with intensity varying from being moderate to severe. The onset of the pain is sudden and is common during strenuous physical activities (Kuo et al., 2015)

Pertinent positive: pelvic region/lower left abdominal pain

Pertinent negative: none present

Differential diagnosis

Pelvic inflammatory Disease

It is characterized by acute onset of | PLACE YOUR ORDER NOW AT writtask.com | organ tenderness, genital tract inflammation. Findings can be nonspecific (Ross & Chacko, 2019).

Pertinent positive: left lower abdominal/pelvic region pain

Pertinent negative: left side

Diverticulitis

It is characterized by constant pain | PLACE YOUR ORDER NOW AT writtask.com | several days before presentation. The pain may be associated with nausea or vomiting.

Pertinent positive: left lower abdominal/pelvic region pain

Pertinent negative: Pain lasting for six hours

P

1. Pelvic examination
2. Abdominal ultrasound
3. Urinalysis, CBC, HcG
4. Laparoscopy
5. Transvaginal/pelvic ultrasound
6. Oral analgesics include Ibuprofen 600mg and Tylenol 500mg.
7. Provide patient with education about disease and oral analgesic medication

Uncomplicated cases should be observed as | PLACE YOUR ORDER NOW AT writtask.com | unstable should be treated as | PLACE YOUR ORDER NOW AT writtask.com | return to the clinic in 48-72 hours if the pain increases or starts experiencing lightheadedness.

Prevention

There are no known prevention methods for the condition.  The condition is treated using surgical drainage or removal of the cyst.

References

Ross, J., & Chacko, M. (2019). Pelvic inflammatory disease: Clinical manifestations and diagnosis.

Kuo, H. W., Chan, C. Y., Lim, K. E., & Chang, H. C. (2015). Ruptured ovarian cystic teratoma with peritoneal reaction: a case report. Journal of Radiological Science, 40(2), 61-64.