Case 2Chief Complaint
(CC) Case 2 “I have pain during intercourse and urination”“Case 3 My back hurts so bad I can barely walk”History of Present Illness (HPI)Case 2 A 19-year-old female reports to you that she has “sores” on and in her vagina for the last three months. A 35-year-old male painter presents to your clinic with the complaint of low back pain. He recalls lifting a 5-gallon paint can and felt an immediate pull in the lower right side of his back. This happened 2 days ago and he had the weekend to rest, but after taking Motrin and using heat, he has not seen any improvement. His pain is sharp, stabbing, and he scored it as a 9 on a scale of 0 to 10.Drug HxCase 2She tries to practice safe sex but has a steady boyfriend and figures she doesn’t need to be so careful since she is on the birth control pill Case 3 Motrin for painFamily Hx NoneCase 3 Father hypertension
Mother DMCase 3 He is having some right leg pain but no bowel or bladder changes. No numbness or tinglingSubjective Case 2 states “I have. sores and bumps on the inner creases of my thighs and pelvic area”. “There is yellowish discharge from the sores that comes and goes”
Case 2 temperature: 100.2°F; pulse 92; respirations 18; BP 122/78; weight 156 lbs, 25 lbs overweight; height 5′3′′
Case 3 temperature: 98.2°F, respiratory rate 16, heart rate 90, blood pressure 120/60
O2 saturation 98%
Generalpatient appears to have good hygiene; minimal makeup, pierced ears, no tattoos; well nourished (slightly overweight); no obvious distress notedwell-developed healthy 35-year-old male; no gross deformities HEENTAtraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition. Piercing in her right nostril and lower lip.
Atraumatic, normocephalic, PERRLA, EOMI, sclera with mild icterus, nares patent, nasopharynx clear, poor dentition – multiple carries. Lungswithin normal limits, appropriate lung sounds auscultated, clear and equal bilaterally
CTA AP&LCardregular rate and rhythm (RRR)S1S2 without rub or gallopS1S2 without rub or gallopBreast
• INSPECTION: no dimpling or abnormalities noted upon inspection
• PALPATION: Left breast no abnormalities noted. Right breast: denies tenderness, pain, no abnormalities noted.
• INSPECTION: no dimpling or abnormalities noted upon inspection
• PALPATION: Left breast – no abnormalities noted. Right breast – denies tenderness, pain, no abnormalities noted.
LymphInguinal Lymph nodes: tenderness bilaterally, numerous, 1 cm in sizeno bruising, fever, or swelling noted, no acute bleeding or trauma to skin.Abdtender during palpation; the left lower quadrant was very tender during palpation; patient denies nausea or vomitingbenign, normoactive bowel sounds x 4; Hepatomegaly 2cm below the costal margin.GU.labia major and minor: numerous ulcerations, too many to count; some ulcerations enter the vaginal introitus; no ulcerations in the vagina mucosa; cervix is clear, some greenish discharge; bimanual exam reveals tenderness in left lower quadrant; able to palpate the left ovary; unable to palpate the right ovary; no tenderness; uterus is normal in size, slight tenderness with cervical mobilityBladder is non-distended.Integumentintact without lesions masses or rashes.MS.Muscles are smooth, firm, symmetrical. Full ROM. No pain or tenderness on palpation.No obvious deformities, masses, or discoloration. Palpable pain noted at the right lower lumbar region. No palpable spasms. ROM limited to forward bending 10 inches from floor; able to bend side to side but had difficulty twisting and going into extension. NeuroNo obvious deficits and CN grossly intact II-XIIDTRs 2+ lower sensory neurology intact to light touch and patient able to toe and heel walk. Gait was stable and no limping noted.
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