What are your top three differential diagnoses

Reference no: EM133636052

Case: Rachel Smith is a 20 y/o female who presents to your urgent care clinic with complaints of yellowish discharge and dysuria x 1 week. She was last seen at this clinic 3 months ago to discuss birth control options. At that time, she decided on an IUD. She was not having any complaints at that time. The only labs she has ever had performed are CBC, glucose, and urine during a primary care wellness check. They were all normal. The IUD was placed about 3 months ago and the patient has had no complaints about it or problems with it.

Vital Signs: BP 132/76; HR 80; RR 16, Temp 98.8, Wt 118 #; Ht: 5'5" Medications: None. IUD placed 3 months ago. Her medical record information is included for you (see below). Past Medical History: Allergies: NKDA Past Medical History: Negative Family History: Mother age 48 alive, no health history Father age 50, alive with high blood pressure (hypertension) Maternal grandmother alive age 70 with high blood pressure (hypertension) Maternal grandfather deceased age 55 due to motor vehicle accident (MVA) Paternal grandmother alive age 72 with Type II diabetes Paternal grandmother alive age 70 with high blood pressure (hypertension) Sister alive age 15, no health problems Immunizations: Up to date. Social History: • Tobacco: ½ pack of cigarettes per day • ETOH: none • substances- none: none • Employment: part-time cashier at the Dollar General • Housing resides with parents and sibling.

What additional questions do you have for her current concern?

What additional past medical history questions do you have?

What are your top three differential diagnoses? List the positives and negatives of each differential. What is the treatment for each of these differential diagnoses?

What, if any, lab tests do you need to make the diagnosis?

What patient education and follow up will you provide?

Reference no: EM133636052

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