Subjective
Prompt #1
A 23-year-old female with complaints of severe left lower abdominal/pelvic pain for 6 hours
Chief Complaint
Severe left lower abdominal/pelvic pain lasting for 6 hours by the moment of the examination.
History of Present Illness
The onset of the presenting condition occurred six hours prior to the visit, as the patient was at her home. The patient describes the pain as acute and located in the left lower section of the abdomen and pelvis. Five hours after the onset, the patient made the decision to visit a healthcare facility for examination. The severity of the pain is subjectively rated as 7 out of 10.
History
The patient is a 23-yeard Master’s student living with her fiancée and reports being sexually active with a single partner. The patient denies the use of contraception of any kind or past abortions. The last menstrual period is reported to have been three to four weeks prior to the examination. At the age of 14, the patient underwent appendicitis surgery. The patient denies having any chronic conditions, as well as smoking and alcohol consumption. A follow-up discussion of the patient’s history is needed to reveal the patient’s dietary habits and physical activity patterns.
Current Medications, Allergies
The patient denies having known allergies or taking medications on a regular basis.
Objective
Vital Signs
According to the preliminary examination, the patient’s blood pressure is 125/75 with a heart rate of 70 and an oral temperature of 99.9.
Physical Exam Findings
The abdomen is slightly swollen and responds with pain to palpation. An old scar from the appendicitis surgery is noticeable in the right lower part of the abdomen. Neither vaginal bleeding nor abnormal vaginal discharge is observed. The skin tone in the abdominal and pelvic areas is normal without the signs of rashes.
Laboratory Data
The patient’s condition requires certain lab data for the complete diagnosis. Ultrasound imaging of the lower abdomen and the uterus is needed. In addition, the patient is to complete blood and urine tests.
Assessment
Problem
The primary problematic condition is enabled by the persistence of abdominal pain.
Differential Diagnoses
- Menstrual Cramps
- Pregnancy (including ectopic pregnancy (EP))
- Sexually Transmitted Diseases (STD) and their complications
Working Diagnosis
- Severe Menstrual Cramps
Plan
The presenting condition requires a multi-stage plan that would determine the exact causes of it and enable a directed treatment procedure. The presence of severe pain in the lower abdomen and pelvis may be characteristic of several mutually exclusive conditions. The lack of birth control combined with an active sexual life of the patient increases the likelihood of an unplanned pregnancy—the reported severity of the points toward a possibility of EP. However, Lee et al. (2019) list vaginal bleeding among the prevailing symptoms of such a complication. In addition, the patient denies having past pregnancies, meaning that it is not certain how her body would react to a normal pregnancy. The patient’s menstrual cycle timeline suggests that the menstrual cramps are most likely the cause of the severe pain. Even though the patient reports no similar instances during previous periods, research indicates that dysmenorrhea may develop as a young adult’s body continues to form (Goel & Maurya, 2019). The presence of an STD is another possibility, but it appears the least likely, despite the lack of contraception, as the patient reports being in a monogamous long-term sexual relationship.
First of all, blood and urine tests are needed to eliminate the possibility of STD-conditioned pain. Second, it is vital to ensure that the patient is not currently pregnant before prescribing any pharmacological treatment. To do so, ultrasound imaging combined with a clinical pregnancy test is required. If strong painkillers are administered before that, they may affect the development of the fetus. Goel and Maurya (2019) argue that the use of the herb is a safe yet effective option for the treatment of dysmenorrhea, but this effect is observed in the long term. Accordingly, this intervention is to be a part of the post-discharge recommendation. At the current stage, precise lab data are needed to acquire a complete understanding of the condition.
References
Goel, B., & Maurya, N. K. (2019). Overview: Herbs used in the treatment of primary dysmenorrhea (menstrual cramps). Advances in Zoology and Botany, 7(3), 47–52. Web.
Lee, R., Dupuis, C., Chen, B., Smith, A., & Kim, Y. H. (2018). Diagnosing ectopic pregnancy in the emergency setting. Ultrasonography, 37(1), 78–87. Web.