GENITALIA ASSESSMENT Subjective: CC: dysuria and urinary frequency HPI: RG is a 30 year old female with increase urinary frequency and dysuria that began 3 days ago. Pain is intermittent and described a burning only in urination, but c/o flank pain since last night. Reports intermittent chills and fever. Used Tylenol for pain with no relief. She rates her pain 6/10 on urination. Reports a similar episode 3 years ago. PMH: UTI 3 years ago PSHx: Hysterectomy at 25 years Medication: Tylenol 1000 mg PO every 6 hours for pain FHx: Mother breast cancer ( alive) Father hypertension (alive) Social: Single, no tobacco , works as a bartender, positive for ETOH Allergies: PCN and Sulfa LMP: N/A Review of Symptoms: General: Denies weight change, positive for sleeping difficulty because e the flank pain. Feels warm. Abdominal: Denies nausea and vomiting. No appetite Objective: VS: Temp 100.9; BP: 136/80; RR 18; HT 6’.0”; WT 135lbs Abdominal: Bowel sounds present x 4. Palpation pain in both lower quadrants. CVA tenderness Diagnostics: Urine specimen collected, STD testing Assessment: UTI STD Instructions: Consider what history would be necessary to collect from the patient in the case study. Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis? Identify at least five possible conditions that may be considered in a differential diagnosis for the patient. The Lab Assignment Using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature. Analyze the subjective portion of the note. List additional information that should be included in the documentation. Analyze the objective portion of the note. List additional information that should be included in the documentation. Is the assessment supported by the subjective and objective information? Why or why not? Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis? Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.
