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Analyze the subjective portion of the note

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.

 

Genitourinary Assessment

 

CC: Increased frequency and pain with urination

 

HPI:

 

T.S. is a 32-year-old woman who reports that for the past two days, she has dysuria, frequency, and urgency. Has not tried anything to help with the discomfort. Has had this symptom years ago. She is sexually active and has a new partner for the past 3 months.

 

Medical History:

 

None

 

Surgical History:

 

Tonsillectomy in 2001

Appendectomy in 2020

Review of Systems:

 

General: Denies weight change, positive for sleeping difficulty because e the flank pain. Feels warm.

Abdominal: Denies nausea and vomiting. No appetite

Objective

 

VSS T = 37.3°C, P = 102/min, RR = 16/min, and BP = 116/74 mm Hg.

 

Pelvic Exam:

 

mild tenderness to palpation in the suprapubic area

bimanual pelvic examination reveals a normal-sized uterus and adnexae

no adnexal tenderness.

No vaginal discharge is noted.

The cervix appears normal.

Diagnostics: Urinalysis, STI testing, Papsmear

 

Assessment:

 

UTI

STI

PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

To Prepare

Review the Episodic note case study

Based on the Episodic note case study:

Review this week’s Learning Resources, and consider the insights they provide about the case study. Refer to Chapter 3 of the Sullivan resource to guide you as you complete your Lab Assignment.

Search the Walden library or the Internet for evidence-based resources to support your answers to the questions provided.

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.

 

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