Assessing the Genitalia and Rectum Discussion 5

Assessing the Genitalia and Rectum Discussion 5

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:

UTI

STD

Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum

You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes.

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