Discussion Part Two (graded)
Further Data
Vital Signs: Height: 160cm Weight: 70 kg, B/P:120/62, T: 99.2, HR: 100, 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 2/4 bil; neck supple w/o lymphadenopathy.
Breast Exam: Tanner IV female with large pendulous breasts bil. No nipple discharge. No nodules. Tenderness and erythema in a 6cm oval area to the right breast in the upper outer quadrant and into the tail of Spence. Right axilla lymphadenopathy noted.
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; peripheral pulses reg., equal, intact; pelvic exam reveals sl. injected vaginal mucosa with a moderate whitish discharge. Erythema to the inside of the labia minora also noted.
Urinalysis in the office: Cloudy amber yellow urine, Sp. Gr. 1.010, positive WBCs, nitrites, and leukoesterase; negative for RBCs, glucose, and ketones.
Wet mount: Positive for Spores, Hyphae and clue cells.
***You note in the chart that Kayla never responded to your contact about her PAP results from several weeks ago. Her results showed ASCUS
Discussion 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
ScholarMatic: Explanation & Answer
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