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

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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

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

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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.

SAMPLE SOLUTION

Genitalia Assessment

Subjective Data Subjective data is a piece of information recorded from the patient’s view or perception concerning their illness. The process of taking subjective data involves the doctor or nurse inquiring from the patient about their illness and recording what they say. The inquiry process is in the form of an interview. From the clinical scenario, the presenting complaint was dysuria | PLACE YOUR ORDER NOW AT writtask.com | history of presenting illness, flank pain was recorded. The history of flank pain should have been first recorded under the chief complaints. In the history of presenting illness, the complaints would have been arranged in order starting from the one that started and how the progression | PLACE YOUR ORDER NOW AT writtask.com | describing pain, it is crucial to record its onset, site, duration, character, relieving factors, and aggravating…