Week 4: Discussion Part Two
No unread replies. No replies.
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
ScholarMatic: Explanation & Answer
Your ready answer from a verified tutor is just a click away for as little as $14.99
Click Order Now to get 100% Original Answer Customized to your instructions!
