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Make a comment using your own words in each discussion but please provide at least one reference for each comment.

Do a half page for discussion #1 and another half page for discussion #2 for a total of one page.

Provide the comment for each discussion separate.

Discussion #1

Discuss the questions that would be important to include when interviewing a patient with this issue.

• Describe the clinical findings that may be present in a patient with this issue.

Clinical findings that may be present in a patient with abdominal pain can vary greatly depending on what the origin of the abdominal pain is. It is common for individuals with abdominal pain to experience intermittent epigastric pain aggravated by stress and food, achy pelvic pain that is worsened by sexual intercourse as well as activity, as well as nausea and vomiting. Abdominal pain is sometimes difficult to initially diagnose and assess because there are many differential diagnoses for someone experiencing abdominal pain. Therefore, it is important during the physical and history to gather all of the clinical findings the patient is experiencing to come to the appropriate diagnosis (Schuiling & Likis, (2016).

• Are there any diagnostic studies that should be ordered on this patient? Why?

Diagnostic studies that should be ordered for this patient would include a pelvic exam with a pap, as we know this patient had a history of an abnormal pap smear. After the abnormal pap resulted, the patient failed to follow up with the office for further evaluation and continuous assessment of her abnormal pap results to check for HPV. A vaginal wet mount should also be ordered for the patient as vaginal discharge is present in the vaginal cavity. The wet mount is used to assess vaginal discharge for  bacteria, yeast cells, trichomoniasis (trichomonads), white blood cells that show an infection, or clue cells that show bacterial vaginosis. If an infection is present, this could attribute to the pelvic and abdominal pain the patient is experiencing. The patient should also be tested for other STDs such as chlamydia and gonorrhea. Lastly, a urinalysis should be done to determine if there is an infection of the urinary tract, as well as a pregnancy test if HCG is detected in the patient’s urine. If necessary, a pelvic ultrasound can always be ordered in order to visualize the internal structures of the pelvic area. This would depict if there are any abnormal masses such as tumors or cysts (Hawkins, Roberto-Nicholas, & Stanley-Haney,  (2016). 

• List the primary diagnosis and three differential diagnoses for this patient. Explain your reasoning for each.

The primary diagnosis for this patient is a trichomonas infection, which is a sexually transmitted disease. Trichomonas parasite was found after microscopic examination of the patient’s vaginal discharge. Most women who experience this type of infection have foul smelling vaginal discharge with pain in the pelvic area. Vaginal irritation, inflammation, and odor is quite common. 

One differential diagnosis for the patient is an ectopic pregnancy. When a woman is experiencing an ectopic pregnancy, she may have abdominal pain that comes and goes, as well as an abnormal pelvic exam. Bloating, nausea and cramping are all symptoms that are also experienced. 

Another differential diagnosis is trauma. As the provider in this case study gathered more information regarding the patient’s exposure to domestic violence, the diagnosis of trauma becomes validated. Present on this patient’s abdomen were bruises sustained after her husband hit her when she mentioned that she might be pregnant. The patient’s abdominal pain in part can also be a somatization of stress due to the trauma endured. 

The last differential diagnosis for this patient is normal pregnancy. We know this patient has not used any sort of birth control in a few years and has had nausea and vomiting. Vaginal discharge of leukorrhea is normal throughout pregnancy. This is why a wet mount is important for evaluation of the vaginal discharge. 

• Discuss your management plan for this patient, including pharmacologic therapies, tests, patient education, referrals, and follow-ups.

Management for this patient would first involve testing the patient in order to determine the cause of her pelvic pain. A pelvic exam and pap must be completed on the patient to assess for any abnormalities. A urinalysis and wet mount of the patient’s vaginal discharge must also be completed. Once we have ruled out pregnancy and determined the patient’s discharge is coming from a trichomonas infection.  We must proceed with treatment of the patient’s STD infection with an antibiotic, metronidazole. It is important to educate the patient that both she and her husband need to take these medications. Next, we must have ongoing management of this patient’s feeling of safety in her home, as there are many indicators that her husband has been abusive to her and potentially her son as well, especially while he is drinking. The provider must educate the patient on all of the resources available to her and provide reassurance, console and empower the patient to get out of her dangerous situation. We should give her the number to the domestic violence hotline, as well as get the patient a counselor with regard to her situation. 

Discussion #2

A patient who presents with bilateral upper and lower quadrant abdominal pain as well as painful intercourse, nausea, vomiting, loose stools and constipation, the provider should take a thorough history and interview to start to rule out many high risk diagnoses. It is important to ask about her pain using OLDCARTSS to gather information. Asking the patient when the pain started, to describe the pain, location, asking whether it radiates or travels anywhere else, any associated symptoms such as nausea or cramping and asking whether she has tried anything for pain relief. It is also important to ask if the patient has had this pain before in the past, and if she knows anything that changed in her life/diet in the time frame that the symptoms began. Because she also complains of pelvic pain and pain during intercourse, it is important to take a thorough gynecological history as well. Does the patient have a history of abnormal PAPs, any history of STDs, or any gynecological surgeries? How are her cycles; are they regular, when was her last menstrual cycle, has there been any vaginal discharge, odor, burning or itching noted? Is the patient sexually active, and if so, does she use protection or is there any risk of STDs? Has the patient been pregnant, and if so were there any complications?(Schuiling & Likis, 2017).

When the patient began mentioning stress repeatedly to the provider, it then became equally important to discuss her mental health as well as her overall safety and well-being. If as the provider you are concerned there may be any form of abuse, it is imperative to ask the patient about any safety concerns. Based on her delay in treatment after having an irregular PAP, her diffuse abdominal pain, bruising noted to her abdomen, repeated mention of stress, history of STD and now painful intercourse, as the provider it is important to expand upon these safety concerns with the patient as these are all red flags for IPV or Intimate Partner Violence. Women who are victims of IPV are more likely to have known red flags such as migraines, painful intercourse, chronic pain syndrome, GI upset such as abdominal pain, nausea, vomiting, diarrhea, constipation, PID, depression, anxiety and PTSD (Schuiling & Likis, 2017).

Because the typical discussion of IPV is led by interview and discussion of the patient’s current situation, because she presents with symptoms that could also be related a serious diagnosis, it is important to perform/order any tests that may be needed to rule out those other diagnoses. Because the patient has had an abnormal PAP in the past with no follow-up, as well as pelvic pain, it is important to perform a pelvic exam with a PAP smear. It is important to also swab for any bacteria or STDs that the patient may have at this time, as well as the blood work for any STDs. A KOH/saline wet prep slide will allow the provider to look at the cells to see if there is any bacterial Vaginosis or yeast that may be growing. Because of the diffuse abdominal pain and pelvic pain, I would also want to order a pelvic and abdominal ultrasound. The ultrasound will help to rule out any ovarian cysts, fibroids, PID, kidney issues. A urine should be collected for Hcg, as well as urinalysis and culture to see if there is any blood, leukocytes, protein etc in the urine, as well as any bacteria growing that could be causing an infection that has then caused the pain she is currently having (Schuiling & Likis, 2017).

Abdominal pain can encompass many diseases, acute and chronic in nature, and as many of them are serious in nature, it is important to keep them on the list of possible diagnoses until ruled out. PID, ectopic pregnancy, appendicitis and trauma are all diagnoses that should be ruled out based on the symptoms she is presenting with. Because the patient has a history of STDs in the past as well as an abnormal PAP, painful intercourse and abdominal pain, PID should be ruled out. Because the pain has been in the lower abdomen for a couple weeks now, and because she is sexually active, it is important to rule out any pregnancy, especially a tubal pregnancy that could be potentially very dangerous for her if not discovered early on. Although there is a low suspicion for appendicitis in this patient based on the timing and location and severity of her pain, it is still important to rule it out so as not to cause any more harm to the patient. Typically appendicitis will present with pain in the right lower quadrant, typically sever and acute in nature. Lastly, because the patient has stated multiple times that she is under a lot of stress, has not answered the question about her safety at home, and has bruises in multiple stages of healing in areas of the body that are not typically known for bruises to be found, it is important to discuss potential abuse/trauma (Schuiling & Likis, 2017).

Based on the interview with the patient and her answers when discussing how safe she feels at home with her partner, it is important to discuss safety plans with the patient. Although the patient may not be open to leaving an abusive situation at this time, the provider needs to respect the decisions of the patient. The patient should be provided with resources to call or go to when needed or at times she may not feel safe. Concerns about her child and his safety should be discussed to ensure the child is in a safe environment. Making sure as the provider you understand the laws for mandated reporting for both the patient and her child is crucial. Performing a safety assessment should be included in the exam, including asking about any weapons in the home, asking about drug and alcohol use for both the patient and her partner, as well as asking if the patient has ever wanted to escape or get help. Making sure the patient understands there are resources for her if and when she chooses to get help in this situation will allow the patient to understand that she is not alone in this situation and that she has someone who cares for her well being (Schuiling & Likis, 2017).