caregiver. She is currently living in an apartment with college friends. Aiyata recently graduated from college and works part‐time as a server. She reports being single since a breakup with her boyfriend. She had been in a mutually monogamous relationship with the boyfriend, but since the breakup, she has had 3 casual sexual partners. She practices safe sex with the use of condoms.
Substance use: She occasionally consumes alcohol 1–2 times a week with 1–2 drinks per setting. She admits to occasional marijuana consumption, but uses no other recreational drugs.
Medications: Oral contraception, Citalopram 20 mg daily.
Allergies: No known drug allergies.
OBJECTIVE
General: Ayita is sad appearing, talking softly, answering questions appropriately.
Vital signs: Temperature: 98.6°F; BP: 120/74; HR: 99; RR: 18.
Skin: Abrasion on left knee and left elbow.
Neurologic: Alert and oriented × 3
HEENT:
Head: Nontender, without masses, hair normally distributed.
Neck: Lateral neck tender to palpation; dark red ecchymosed areas on right side of neck, trachea midline, no lymphadenopathy. Thyroid nontender, without palpable masses or enlargement.
Eyes: PERRLA and EOMs are intact, left eye small subconjunctival hemorrhage.
Oropharynx: Uvula is midline, no edema, redness, or ecchymosis.
Respiratory: Lung sounds are clear to auscultate.
Cardiac: Regular rate and rhythm.
Breast: Tanner IV, symmetrical.
Abdomen: Soft, nontender, nondistended; active bowel sounds.
Pelvic:
Vulva: No lesions or ecchymosis. The labia minora are red and swollen, tender to palpation; there is a small laceration at the posterior fourchette.
Vagina: No active bleeding, very tender with speculum insertion, white discharge in vaginal vault.
Cervix: Bright red and friable; positive cervical motion tenderness.
Rectal: Rugae normal appearance, no lesions.
CRITICAL THINKING
1 What is the most likely differential diagnosis in this case and why?___Sexual assault___Strangulation___Pelvic inflammatory disease
2 Which diagnostic tests are required in this case and why?___CBC with differential___Metabolic panel___LFTs___Toxicology panel___HCG___HIV___Urinalysis___NAAT___CT scan neck___Transvaginal ultrasound___Abdominal ultrasound
3 What are the concerns at this point?
4 What is the plan of treatment?
5 What are the plans for referral and follow‐up care?
6 What health education should be provided to this patient?
7 Are there any standardized guidelines that should be used to assess or treat this case?
Case 6.8 Abdominal Pain
By Leslie Neal‐Boylan, PhD, APRN, CRRN, FAAN, FARN
SUBJECTIVE
Rachel is a 17‐year‐old Caucasian female who presents with complaints of decreased appetite, fatigue, nausea, and intermittent abdominal pain for the past 2–3 weeks. She describes the abdominal pain as sharp and focused in the right epigastric area. She also reports some new‐onset pain in her right shoulder but attributes this to carrying around her baby more than usual. She denies vomiting, diarrhea, or constipation. Her typical diet consists of pizza, hot dogs, and salads. Rachel denies any association of her symptoms with food or hunger. Her last normal menstrual period was 3 weeks ago, and she has had 2 negative pregnancy tests at home.
Past medical history: She delivered her son 6 months ago vaginally without complications. Her only other medical history includes a kidney infection 4 months ago.
Social history: She smokes 7 cigarettes a day but admits, “I really don’t need them. I am bored.” Rachel lives with her boyfriend (the father of her child) and his parents. She moved in, far away from her home, only recently. Her parents made her leave their house when she told them she was pregnant, and they have no contact with her. She states that she feels safe at home and is enjoying her baby. Her boyfriend helps with the baby but often goes out at night with his friends and leaves her at home with the baby. She feels a little isolated because everyone works during the day and she has no access to transportation. She is dependent on her in‐laws if she needs to go anywhere by car, and they do not often support her need to go anywhere. Otherwise, she walks. She walked here today for her appointment.
Medication: She is not allergic to any medication and only takes birth control pills.
OBJECTIVE
Vital signs: Rachel is afebrile. BP is 120/80. Pulse is 68 and regular.
Eyes: PERRLA. EOMs are intact. Optic disks are sharp.
Cardiac: Cardiac exam reveals regular rate and rhythm.
Respiratory: Respirations are 12, steady, and unlabored. Lungs are clear.
Abdomen: Soft with mild tenderness to palpation (TTP) in the RUQ with a positive Murphy’s sign. There is no CVA tenderness.
Genitourinary: A urine dipstick reveals positive protein. A urine HCG is negative.
Rachel is diagnosed at this first visit with possible cholecystitis and is given Antivert 12.5 mg for her nausea.
Blood is drawn and sent to the lab. Her urine is sent for analysis, and she is told to return in 1 week.
Rachel returns 1 week later. Her bloodwork reveals a blood glucose of 45 mg/dL. Her other bloodwork is within normal limits. Her urinalysis returns with few bacteria and no protein. Rachel reports that the abdominal pain has worsened and she now has headaches. She denies a history of migraines or frequent headaches. Her nausea is still present but decreased.
Her exam remains unchanged.
CRITICAL THINKING
1 What is the
