Module 5 Discussion Gastrointestinal & Endocrine For this Discussion, you wil

Module 5 Discussion
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
AllergiesNKA
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 Generalacute 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:
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.
Submission Instructions:
Your post should be at least 500 words, formatted and cited in current APA style with support from at least 2 references from academic journals no older than five years. Grading Rubric Your assignment will be graded according to the grading rubric.
Discussion Rubric
CriteriaRatingsPoints
Identification of Main Issues, Problems, and Concepts
Distinguished – 5 points
Identify and demonstrate a sophisticated understanding of the issues, problems, and concepts.
Excellent – 4 points
Identifies and demonstrate an accomplished understanding of most of issues, problems, and concepts.
Fair – 2 points
Identifies and demonstrate an acceptable understanding of most of issues, problems, and concepts.
Poor – 1 point
Identifies and demonstrate an unacceptable understanding of most of issues, problems, and concepts.
5 points
Use of Citations, Writing Mechanics and APA Formatting Guidelines
Distinguished – 3 points
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.
Excellent – 2 points
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.
Fair – 1 point
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.
Poor – 0 points
Ineffectively uses the literature and other resources to inform their work. An unacceptable use of citations and extended referencing. APA style and writing mechanics need serious attention.
3 points
Response to Posts of PeersDistinguished – 2 points
Student constructively responded to two other posts and either extended, expanded or provided a rebuttal to each.
Fair – 1 point
Student constructively responded to one other post and either extended, expanded or provided a rebuttal.
Poor – 0 points
Student provided no response to a peer’s post.
2 points
Total Points 10