Lab Assignment: Assessing the Genitalia and Rectum

Using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature.

· Review and use the Episodic note case study for this week’s Assignment (see below). Complete with the additional information required for this Assignment

· 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?

· 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?

· Would you reject/accept the current diagnosis? Why or why not? Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

· Explain your reasoning using at least five different references from current evidence-based literature.

· APA 7

EPISODIC NOTE CASE STUDY

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: Lab Assignment: Assessing the Genitalia and Rectum

UTI

STD

Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum

Assignment

–

Instructions

Using

evidence

–

based resources

from your sear

ch, answer the following questions and

support your answers using current evidence from the literature.

Review

and use

the Episodic note case study

for this week’s Assignment

(see

below)

omplete

with the

additional

infor

mation

required for this Assignment

Analyze the subjective portion of the note. List additional information that should be

included in the documentation.

Analyze the objective portion of t

he 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?

Consider what physical exams and diagnostic tests would be appropriate to gather more

information a

bout the patient’s condition. How would the results be used to make a

diagnosis?

Would you reject/accept the current diagnosis? Why or why not?

Identify

at least

five

possible conditions that may be considered in a differential diagnosis for the patient. Lab Assignment: Assessing the Genitalia and Rectum

Explain your reasoning using at least

five

different references from

current evidence

–

based

literature.

PA 7

EPISODIC NOTE CASE STUDY

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

Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum

Assignment – Instructions

Using evidence-based resources from your search, answer the following questions and

support your answers using current evidence from the literature.

 Review and use the Episodic note case study for this week’s Assignment (see below).

Complete with the additional information required for this Assignment

 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?

 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?

 Would you reject/accept the current diagnosis? Why or why not? Identify at least

five possible conditions that may be considered in a differential diagnosis for the patient.

 Explain your reasoning using at least five different references from current evidence-based

literature.

 APA 7

EPISODIC NOTE CASE STUDY

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