Homework: Assessing the Genitalia & Rectum Genitalia
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
Using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature.
o Analyze the subjective portion of the note. List additional information that should be included in the documentation.
o Analyze the objective portion of the note. List additional information that should be included in the documentation.
o Is the assessment supported by the subjective and objective information? Why or why not?
o Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis?
o 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.
Format your homework according to the following formatting requirements:
o The answer should be typed, using Times New Roman font (size 12), double spaced, with one-inch margins on all sides.
o The response also includes a cover page containing the title of the homework, the student's name, the course title, and the date. The cover page is not included in the required page length.
o Also include a reference page. The Citations and references must follow APA format. The reference page is not included in the required page length.