GENITALIA ASSESSMENT

Using evidence-based resources from your search (at least 3 references), answer the following questions and support your answers using current evidence from the literature. This should be a narrative paper.

• 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.

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

Sample Solution

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