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The Lab Assignment

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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 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.

 

(Additional Info: Evidence Based Literature is usually from Peer Reviewed Journals, Research articles or Specialty Group recommendations. There are Evidence Based Web Sources listed in Advance Health Assessment Textbook. Textbooks are not considered Evidence Based Literature.)

 

Week 10 Case Study

 

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 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, Pap smear.

 

Assessment:

> UTI

> STI

 

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

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