NR602 week 4 discussion Pat 2

Week 4: Discussion Part Two

FURTHER DATA

Vital Signs: height: 155 centimeters weight: 71 kilograms, B/P:120/62, T: 99.2, HR: 90, Resp: 16, reg, non-labored, SpO2: 99%

General: Awake, alert, appropriate; well groomed; skin: warm, dry, intact. HEENT: Head normocephalic. Conjunctiva clear, non-icteric, PERRLA, EOM’s intact; tympanic membranes intact, unremarkable; nares patent, unremarkable bil; pharynx unremarkable tonsils 1/4 bil; neck supple w/o lymphadenopathy.

Breast Exam: large pendulous breasts bil. No nipple discharge. No nodules. Three small 2mm erythematous bullous lesions in a linear pattern noted at 9 o’clock on the right breast.

Cardiopulmonary: Heart RRR w/o murmur; lungs CTA throughout; respirations even and unlabored; abdomen, soft, with normoactive bowel sounds throughout.

Abdomen: Normoactive bowel sounds throughout; tenderness to palpation in the super-pubic area; no masses or organomegally

External Genitalia: Mons intact with normal hair distribution, labia majora, minora, clitoris intact, Bartholin’s and Skene’s glands. Intact. No piercings. No hymen. Skin to the labia majora and vulvar area whitish and thickened.

Vagina: Pink, moist, with rugae, no odor, tone good. No rectocele, cystocele, or discharge.

Cervix: pink with multi-parous patent os, no lesions, sl. anterior and freely mobile without tenderness.

Uterus: small, firm, midline, smooth, mobile, non-tender uterus. Adnexae: present, smooth, non-tender.

Urinalysis in the office: Cloudy amber yellow urine, Sp. Gr. 1.010, negative for Questions Part Two:

What is the primary diagnosis for Kayla with rationale?

What is the differential diagnosis with rationale?

Plan for each primary diagnoses based on one current evidence-based guidelines.

Include the following:

Further diagnostic work-up not included above

Medications

Referrals

Conservative measures

Patient education

Follow-up plan

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