What are your initial differential diagnoses

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Reference no: EM133738761

Case: A 21-year-old female college student presents to your clinic a chief complaint of abdominal pain, foul-smelling vaginal discharge, and fever and chills for the past 4 days. She denies nausea, vomiting, or difficulties with defecation. Her last bowel movement this morning was normal for her. Nothing has helped with the pain despite taking ibuprofen 200 mg orally several times a day. She describes the pain as sharp and localizes the pain to her lower abdomen. Past medical history noncontributory. GYN/Social history + for having had unprotected sex while at a fraternity party. Physical exam: thin, Ill appearing anxious looking white female who is moving around on the exam table and unable to find a comfortable position. Temperature 101.6F orally, pulse 120, respirations 22 and regular. Review of systems negative except for chief complaint. A focused assessment of the abdomen demonstrated moderate pain to palpation left and right lower quadrants. The upper quadrants were soft and non-tender. Bowel sounds diminished in bilateral lower quadrants. Pelvic exam demonstrated + adnexal tenderness, + cervical motion tenderness, and copious amounts of thick greenish secretions.

Q: What are your initial differential diagnoses for this patient and why?

Q: What additional information should you obtain?

Q: What additional physical assessments or diagnostic testing should be completed?

Q: How would you treat this patient?

Q: What patient teaching will be incorporated into the visit?

Reference no: EM133738761

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