Hematologic: Susan denies any bleeding or bruising that doesn’t correlate to a specific injury.
Neurologic: Susan reports some numbness and tingling if her hands or feet get too cold, but not otherwise. She denies fainting, dizziness (vertigo), feeling off balance, or having difficulty walking.
Sleep: Susan’s usual bedtime routine includes nighttime washing and tooth brushing followed by reading or watching TV for about 30 minutes. She denies use of stimulants except for coffee each morning. She does wake every night with hot flashes/sweats. She is able to fall back to sleep but reports that it can take up to an hour depending on whether she needs to change her pajamas or sheets and how long it takes to feel cool again. She usually goes to bed around 10 p.m. and falls asleep around 10:30 p.m. She gets up for work around 6 a.m. most days. She reports that she usually does not feel refreshed when she wakes up.
OBJECTIVE
Vital signs: BP: 132/80 (L) sitting; P: 78; RR: 10; weight: 152 lbs; height: 5 ft 7 inches; BMI: 23.8.
General: Appears well; in no apparent distress; neatly dressed; appropriate affect.
HEENT: Head: Nontender; without masses; hair thinning slightly in some areas. Eyes: Clear conjunctivae; PERRLA intact; EOMI; fundi sharp optic discs; normal retinal arterioles; no A‐V nicking. Ears: Clear external auditory canals; TMs + light reflex and landmarks visible; hearing grossly normal. Mouth/Throat: + normal mucosa, tongue, pharynx, and tonsils; dentition in good repair.
Neck: Supple, without lymphadenopathy. Thyroid nontender, without palpable masses or enlargement. Carotids without bruits.
Respiratory: Clear to auscultation and percussion, anterior and posterior; without wheezes, rales, or rhonchi.
Cardiac: RRR: normal S1 and S2 without murmurs, rubs, or gallops.
Breasts: Without masses, skin changes, or discharge bilaterally; no lymphadenopathy.
Abdomen: Soft, nondistended, nontender; + bowel sounds × 4 quadrants; without HSM, masses, or bruits.
Gynecological: Vaginal mucosa slightly dry, rugae present; uterus firm and anteverted, nontender, without palpable masses; adnexa nontender, without palpable masses bilaterally; no lesions noted.
Rectal: No lesions or masses noted; + external hemorrhoids; nontender; + normal sphincter tone.
Extremities: Without cyanosis, edema, or clubbing; +2 pulses bilaterally. + full range of motion throughout, nontender joints without crepitus.
Neurologic: CN II–XII grossly negative; 5/5 motor strength, gait even; DTRs 2+; Romberg negative.
CRITICAL THINKING
1 What are the top three differential diagnoses to consider for Susan and why?
2 Which diagnostic tests are required for managing Susan’s condition and why?
3 What are the concerns at this point?
4 What is the plan of treatment options to be discussed with Susan?
5 What are the recommendations for referral and follow‐up care?
6 What health education should be provided for Susan?
7 What if Susan also had diabetes or hypertension?
8 What if Susan were over age 65?
9 Does Susan’s psychosocial history affect the management recommendations?
10 Are there any standardized guidelines that should be used when developing a management plan for Susan? If so, what are they?
Case 6.4 Pelvic Pain
By Meredith Scannell, PhD, MSN, MPH, CNM, CEN, SANE‐A
SUBJECTIVE
Shanae is a 32‐year‐old female who presents with lower abdominal pain and fever. Fevers at home range between 99.4°F to a maximum of 101.7°F. She describes the lower abdominal pain as a constant dull ache, nonradiating, with a pain scale ranging from 5/10 to 8/10. The pain is worse with sexual intercourse. Shanae is taking acetaminophen 650 mg every 4 hours with minimal relief. She reports general malaise and that for the past 2 weeks she has been having heavy, purulent vaginal discharge. Three weeks ago, Shanae went to an urgent care clinic for dysuria. At that time, there was concern about a sexual transmitted infection and Shanae was treated for gonorrhea and chlamydia.
Past medical history: Polycystic ovarian syndrome, gonorrhea, herpes simplex virus type‐2
Gynecologic history: Two abnormal Pap smears requiring repeat testing and cone biopsy with negative results.
Menstrual history: Menstrual cycles irregular between 28 and 35 days, lasting 5–7 days of heavy bleeding. LMP 1 week ago.
Family history: Mother with history of cervical cancer and died at the age of 38, father with alcohol and substance abuse, no other history known.
Sexual history: Shanae reports having a poor sexual relationship with her husband, from whom she is separated. She left her husband after finding out he was having extramarital relationships and has engaged in several sexual relationships of her own. She now reports current sexual activity as intercourse with only one partner. She and her partner use condoms on most occasions; however, there has been a few occasions when they did not use condoms. She is currently satisfied with her sexual partner with whom she engages in vaginal, oral, and rectal sexual intercourse.
Substance use: Shanae denies use of tobacco. She reports occasional alcohol use of 1–2 drinks per month. She reports daily or near daily smoking of marijuana and has used cocaine in the distant past, none recently.
Safety: Shanae reports feeling safe at home and in her current relationship. She says that the relationship with her husband was beginning to feel unsafe due to constant fighting. Since the separation, she has had no safety concerns and in the process of finalizing a divorce.
Medications: Ibuprofen 600 mg as needed, OCP (Yasmin) once daily.
Allergies: NKDA,
OBJECTIVE
General: Shanae is pleasant but appears in distress, guarding her abdomen.
Vital signs: Temperature: 100.4°F; BP: 100/52; HR: 110; respirations: 24.
Skin: Hot to touch, no lesions, no rashes.
Abdomen: Abdomen + bowel sounds, soft, nondistended. Positive suprapubic pain elicited upon palpation. No rebound tenderness, Turner sign, or Cullen sign.
Pelvic: Cervix midline, friable cervical OS; yellow discharge noted from the OS. Positive cervical motion tenderness. No lymphadenopathy and no adnexal masses.
Rectal: No lesions, no masses; normal sphincter tone.
CRITICAL THINKING
1 What is the most likely differential diagnosis in this case?___Ectopic pregnancy___Pyelonephritis___Pelvic inflammatory disease
2 Which diagnostic tests are required in this case and why?___CBC___Nucleic acid amplification tests (NAAT)___Beta hCG___HIV___Wet mount___Treponema pallidum___Transvaginal